Vitamin D supplementation as a rational pharmacological approach in the COVID-19 pandemic.

The COVID-19 pandemic has reached most of the countries worldwide causing death, which often results from an inflammatory storm associated with severe acute respiratory syndrome (SARS). This has prompted researchers to seek specific novel and definitive treatments urgently. In this context, it is interesting to evaluate the preventive and therapeutic effects of existing pharmacological agents that could be useful. In this regard, vitamin D supplementation, particularly in individuals likely to be deficient, may be a promising option. Vitamin D is a hormone that modulates many of the same inflammatory and oxidative signaling pathways triggered during COVID-19. For example, vitamin D suppresses the actions of the renin-angiotensin system, which has a determining role in the pathophysiology of the inflammatory response related to COVID-19. This paper analyzes the evidence that vitamin D supplementation might be a valuable preventive/therapeutic measure in groups at risk for or infected with COVID-19. It also discusses how clinical studies could be best designed to evaluate the possible advantages of vitamin D supplementation for the benefit of public health during the pandemic.

[Health working conditions and environment: conceptual model for remote and rural areas]. / Condiciones y medio ambiente de trabajo en salud: modelo conceptual para áreas remotas y rurales.

This report proposes a conceptual model on workplace environment and working conditions that integrates the available evidence to facilitate the design and evaluation of interventions aimed at improving the attraction, recruitment and retention of health personnel at the first level of care in rural and remote areas. Theoretical, empirical and testimonial evidence was consulted to support the model, and 15 frameworks disseminated in the last 20 years were synthesized. The article shows the diversity of perspectives and the complexity involved in establishing the dimensions to be considered in a proposal that is useful to apply to human resources for health policies.The proposed model includes four categories of components: factors of the external context, organizational factors, employment and work conditions, and individual factors. The boundaries between the components -as well as the weight and influence of each one- vary according to the interrelationship among them and the interaction with the environment, and thus its interpretation must be adapted to the context in which it is intended to be applied.Based on this conceptual model, the design and evaluation of interventions aimed at increasing the availability of health personnel -particularly at the primary care level in rural and remote areas of the Region of the Americas- should emerge from an interaction between health and employment policies, and the realities and expectations of workers and the communities.

[Factors and interventions that affect working conditions and environment to increase the attraction, recruitment and retention of human resources for health at the primary care level in rural, remote or underserved areas]. / Factores e intervenciones que inciden en las condiciones y medio ambiente de trabajo para incrementar la atracción, captación y retención de recursos humanos en salud en el primer nivel de atención de áreas rurales, remotas o desatendidas.

OBJECTIVE: To identify and systematize available empirical evidence on factors and interventions that affect working conditions and environment in order to increase the attraction, recruitment and retention of human resources for health at the primary care level in rural, remote or underserved areas. METHODS: Rapid review of reviews selected according to relevance, eligibility and inclusion criteria. The search was conducted on electronic and manual databases, including grey literature. AMSTAR I was used to assess the quality of systematic reviews and a thematic analysis for synthesis of the results. RESULTS: Sixteen reviews were included, one of which contained 14 reviews. Of the total, 20 reviews analyzed factors and 9 evaluated the effectiveness of interventions. The evidence on factors is abundant, but of limited quality. Individual, family and "previous exposure to a rural setting" factors were associated with higher recruitment; organizational and external context factors were important for human resource retention. Networking and professional support influenced recruitment and retention. Evidence on the effectiveness of interventions was limited, both in quantity and quality. The most frequently used intervention was incentives. CONCLUSIONS: Evidence on factors that are positively related to recruitment and retention of workers at the first level of care in rural, remote or underserved areas is sufficient and should be taken into account when designing interventions. Quality evidence on the effectiveness of interventions is scarce. More controlled studies with methodological rigor are needed, particularly in the Americas.

Post COVID-19 syndrome. Severity and evolution in 4673 health care workers.

BACKGROUND: The evolution of post COVID syndrome has been variable and we lack information on its impact on healthcare professionals, particularly in Latin America. METHODS: We conducted a survey through a social network in health professionals on post COVID-19 syndrome cases confirmed with PCR. In a web-based questionnaire, we asked about 21 symptoms, their severity, duration, degree of activity impairment and return to work. RESULTS: 4673 health professionals from 21 countries responded, mean age of 47.8 years, 64.2% women. The initial course was asymptomatic in 9.1%, mild symptoms 36.8%, moderate symptoms without hospitalization 40.8% or with hospitalization 11.7%, and severe symptoms with respiratory assistance 1.6%. The most prevalent symptoms were fatigue (67%), insomnia (44.2%), anxiety (42.3%), myalgia (41.9%) and anosmia (41.2%). Considering only severe symptoms (grades 3-4 on a subjective index from 1 to 4), the most prevalent were slowness (36.3%), impaired concentration (33.1%), anosmia (20.4%), fatigue (19.1%), impaired memory (18.1%) and dyspnea (15.9%). Prevalence dropped by half in the first 5 five months, but in many cases, it lasted for more than a year. In the multivariate analysis, symptoms tended to be grouped into clusters (cognitive, neuropsychiatric, cardiorespiratory, digestive, others). The need to change the work area was 16% and lack of return to work 7.8%, related to older age, number of symptoms and severity of the initial course. CONCLUSION: In conclusion, in many cases the persistence of post-COVID symptoms can be prolonged and have an occupational impact on healthcare professionals, requiring the adoption of specific policies to reduce harm.

Introducción: La evolución del síndrome post COVID ha sido variable y carecemos de información sobre su impacto en los profesionales de la salud. Métodos: Realizamos una encuesta a través de una red social en profesionales de la salud sobre casos de síndrome post COVID-19 confirmados con PCR. En un cuestionario web, preguntamos sobre 21 síntomas, su gravedad, duración, grado de afectación de la actividad y reincorporación al trabajo. Resultados: Respondieron 4673 profesionales sanitarios de 21 países, edad media de 47 años, 64% mujeres. El curso inicial fue asintomático en el 9%, síntomas leves en el 36%, síntomas moderados sin hospitalización en el 40% o con hospitalización en el 11%, y síntomas graves en el 1%. Los síntomas más prevalentes fueron fatiga (67%), insomnio (44%), ansiedad (42%), mialgia (41%) y anosmia (41%). La prevalencia se redujo a la mitad en los primeros 5 cinco meses, pero en muchos casos se prolongó durante más de un año. En el análisis multivariado los síntomas tendieron a agruparse en clusters (cognitivos, neuropsiquiátricos, cardiorrespiratorios, digestivos, otros). La necesidad de cambiar de área de trabajo fue del 16% y la falta de reincorporación al trabajo del 7%, relacionadas con la mayor edad, el número de síntomas y la gravedad del curso inicial. Conclusión: En muchos casos la persistencia de los síntomas post-COVID puede ser prolongada y tener un impacto laboral en los profesionales sanitarios, requiriendo la adopción de políticas específicas para reducir el daño.

Circulating microRNAs as biomarkers of Chagas cardiomyopathy.

Background: Chagas cardiomyopathy (CHCM) is the most important clinical manifestation of Chagas disease. The analysis of cardiac miRNAs may contribute to predicting the progression to CHCM in Chagas indeterminate phase and/or to the differential diagnosis for cardiomyopathy. Methods: We carried out a case-control study to identify circulating miRNAs associated with CHCM. We assigned 104 participants to four groups: healthy controls (HC), Chagas non-cardiomyopathy controls, CHCM cases, and ischemic cardiomyopathy controls. We performed a clinical, echocardiographic, and laboratory evaluation and profiled circulating miRNA in the serum samples. Results: Differences between groups were observed in clinical variables and in the analysis of miRNAs. Compared to HC, CHCM participants had 4 over-expressed and 6 under-expressed miRNAs; miR-95-3p and miR-130b-3p were upregulated in CHCM compared with controls, Chagas non-cardiomyopathy and ischemic cardiomyopathy participants, suggesting that might be a hallmark of CHCM. Analysis of gene targets associated with cardiac injury yielded results of genes involved in arrhythmia generation, cardiomegaly, and hypertrophy. Conclusions: Our data suggest that the expression of circulating miRNAs identified by deep sequencing in CHCM could be associated with different cardiac phenotypes in CHCM subjects, compared with Chagas non-CHCM, ischemic cardiomyopathy controls, and healthy controls.

Sex Differences in the Clinical Presentation of Acute Coronary Syndromes.

The clinical presentation of acute coronary syndromes (ACS) as ST-elevation ACS (STEACS) or non-ST-elevation ACS (NSTEACS) differs between women and men. The aim of this study was to describe the difference in the clinical presentation of ACS between sexes. A total of 10,019 patients included in the Epi-Cardio Registry were analyzed. A higher proportion of women than men presented with NSTEACS (60.3% vs 46.7%; P <0.001). The difference between sexes was driven by a higher prevalence of ACS with non-obstructive coronary arteries (20.9% vs 6.6%) mainly in young women, since ACS without coronary lesions were mostly NSTEACS (77.7% vs 22.3%). In patients with obstructive coronary heart disease, there were no differences in the clinical presentation between sexes. In conclusion, younger women are more likely than men to present ACS with non-obstructive coronary arteries, whereas no significant difference exists between sexes regarding the prevalence of ACS with obstructive coronary artery disease.

Intramyocardial Dissecting Hematoma: A Mechanical Complication Needing Surgical Therapy?

Intramyocardial dissecting hematoma is a form of cardiac rupture caused by myocardial infarction, percutaneous coronary intervention, or trauma. It is a cavity between myocardial fibers caused by partial rupture of the ventricular wall. Therapeutic management, including the timing for surgical approach, has not been standardized. We present a case series describing 4 patients. (Level of Difficulty: Intermediate.).

High-dose vitamin D versus placebo to prevent complications in COVID-19 patients: Multicentre randomized controlled clinical trial.

BACKGROUND: The role of oral vitamin D3 supplementation for hospitalized patients with COVID-19 remains to be determined. The study was aimed to evaluate whether vitamin D3 supplementation could prevent respiratory worsening among hospitalized patients with COVID-19. METHODS AND FINDINGS: We designed a multicentre, randomized, double-blind, sequential, placebo-controlled clinical trial. The study was conducted in 17 second and third level hospitals, located in four provinces of Argentina, from 14 August 2020 to 22 June 2021. We enrolled 218 adult patients, hospitalized in general wards with SARS-CoV-2 confirmed infection, mild-to-moderate COVID-19 and risk factors for disease progression. Participants were randomized to a single oral dose of 500 000 IU of vitamin D3 or matching placebo. Randomization ratio was 1:1, with permuted blocks and stratified for study site, diabetes and age (≤60 vs >60 years). The primary outcome was the change in the respiratory Sepsis related Organ Failure Assessment score between baseline and the highest value recorded up to day 7. Secondary outcomes included the length of hospital stay; intensive care unit admission; and in-hospital mortality. Overall, 115 participants were assigned to vitamin D3 and 105 to placebo (mean [SD] age, 59.1 [10.7] years; 103 [47.2%] women). There were no significant differences in the primary outcome between groups (median [IQR] 0.0 [0.0-1.0] vs 0.0 [0.0-1.0], for vitamin D3 and placebo, respectively; p = 0.925). Median [IQR] length of hospital stay was not significantly different between vitamin D3 group (6.0 [4.0-9.0] days) and placebo group (6.0 [4.0-10.0] days; p = 0.632). There were no significant differences for intensive care unit admissions (7.8% vs 10.7%; RR 0.73; 95% CI 0.32 to 1.70; p = 0.622), or in-hospital mortality (4.3% vs 1.9%; RR 2.24; 95% CI 0.44 to 11.29; p = 0.451). There were no significant differences in serious adverse events (vitamin D3 = 14.8%, placebo = 11.7%). CONCLUSIONS: Among hospitalized patients with mild-to-moderate COVID-19 and risk factors, a single high oral dose of vitamin D3 as compared with placebo, did not prevent the respiratory worsening. TRIAL REGISTRATION: ClincicalTrials.gov Identifier: NCT04411446.

Applying systems thinking to identify enablers and challenges to scale-up interventions for hypertension and diabetes in low-income and middle-income countries: protocol for a longitudinal mixed-methods study.

INTRODUCTION: There is an urgent need to reduce the burden of non-communicable diseases (NCDs), particularly in low-and middle-income countries, where the greatest burden lies. Yet, there is little research concerning the specific issues involved in scaling up NCD interventions targeting low-resource settings. We propose to examine this gap in up to 27 collaborative projects, which were funded by the Global Alliance for Chronic Diseases (GACD) 2019 Scale Up Call, reflecting a total funding investment of approximately US$50 million. These projects represent diverse countries, contexts and adopt varied approaches and study designs to scale-up complex, evidence-based interventions to improve hypertension and diabetes outcomes. A systematic inquiry of these projects will provide necessary scientific insights into the enablers and challenges in the scale up of complex NCD interventions. METHODS AND ANALYSIS: We will apply systems thinking (a holistic approach to analyse the inter-relationship between constituent parts of scaleup interventions and the context in which the interventions are implemented) and adopt a longitudinal mixed-methods study design to explore the planning and early implementation phases of scale up projects. Data will be gathered at three time periods, namely, at planning (TP), initiation of implementation (T0) and 1-year postinitiation (T1). We will extract project-related data from secondary documents at TP and conduct multistakeholder qualitative interviews to gather data at T0 and T1. We will undertake descriptive statistical analysis of TP data and analyse T0 and T1 data using inductive thematic coding. The data extraction tool and interview guides were developed based on a literature review of scale-up frameworks. ETHICS AND DISSEMINATION: The current protocol was approved by the Monash University Human Research Ethics Committee (HREC number 23482). Informed consent will be obtained from all participants. The study findings will be disseminated through peer-reviewed publications and more broadly through the GACD network.

High-dose vitamin D versus placebo to prevent complications in COVID-19 patients: A structured summary of a study protocol for a randomised controlled trial (CARED-TRIAL).

OBJECTIVES: To evaluate whether a single high dose of oral cholecalciferol improves the respiratory outcomes as compared with placebo among adults COVID-19 patients at moderate risk of clinical complications. TRIAL DESIGN: The CARED trial is an investigator-initiated, multicentre, randomized, parallel, two-arm, sequential, double-blind and placebo-controlled clinical trial. It was planned as a pragmatic trial since the inclusion criteria are broad and the study procedures are as simple as possible, in order to be implemented in the routine clinical practice in general wards in the pandemic setting and a middle-income country context. The sequential design involves two stages. The first stage will assess the effects of vitamin D supplementation on blood oxygenation (physiological effects). The second stage will assess the effects on clinical outcomes. PARTICIPANTS: Participants of either gender admitted to general adult wards in 21 hospital sites located in four provinces of Argentina are invited to participate in the study if they meet the following inclusion criteria and none of the exclusion criteria: Inclusion criteria SARS-CoV-2 confirmed infection by RT-PCR; Hospital admission at least 24 hours before; Expected hospitalization in the same site ≥24 hours; Oxygen saturation ≥90% (measured by pulse oximetry) breathing ambient air; Age ≥45 years or at least one of the following conditions: ○ Hypertension; ○ Diabetes; ○ At least moderate COPD or asthma; ○ Cardiovascular disease (history of myocardial infarction, percutaneous transluminal coronary angioplasty, coronary artery bypass grafting or valve replacement surgery); ○ Body mass index ≥30; Willingness to sign informed consent (online supplementary material 1 and 2). EXCLUSION CRITERIA: Age <18 years; Women in childbearing age; >= 72 hs since current admission; Requirement for a high dose of oxygen (>5 litres/minute) or mechanical ventilation (non-invasive or invasive); History of chronic kidney disease requiring haemodialysis or chronic liver failure; Inability for oral intake. Chronic supplementation with pharmacological vitamin D; Current treatment with anticonvulsants; History of: ○ Sarcoidosis; ○ Malabsorption syndrome; ○ Known hypercalcemia or serum calcium >10.5 mg/dL; Life expectancy <6 months; Known allergy to study medication; Any condition at discretion of investigator impeding to understand the study and give informed consent. INTERVENTION AND COMPARATOR: The intervention consists in a single oral dose of 500.000 IU of commercially available cholecalciferol soft gel capsules (5 capsules of 100.000 IU) or matching placebo MAIN OUTCOMES: The primary outcome for the first stage is the change in the respiratory Sepsis-related Organ Failure Assessment (SOFAr) score between pre-treatment value and the worst value recorded during the first 7 seven days of hospitalization, the death or discharge, whichever occurs first. The SOFAr score measured as the ratio between the pulse oximetry saturation (SpO2) and FiO2 (27, 28) is used instead of the arterial partial pressure of oxygen (PaO2). SOFAr score is a 4-points scale, with higher values indicating deeper respiratory derangement as follows: 1 PaO2 <400; 2 PaO2 <300; 3 PaO2 <200; 4 PaO2 <100. The primary outcome for the second stage is the combined occurrence of requirement ≥40% of FiO2, invasive or non-invasive ventilation, up to 30 days or hospital discharge. RANDOMISATION: A computer-generated random sequence and the treatment assignment is performed through the web-based randomization module available in the electronic data capture system (Castor®). A randomization ratio 1:1, stratified and with permuted blocks was used. Stratification variables were diabetes (yes/no), age (≤60/>60 years) and the site. BLINDING (MASKING): Double-blind was achieved by using placebo soft gel capsules with the same organoleptic properties as the active medication. Central management of the medication is carried out by a pharmacist in charge of packaging the study drug in unblinded fashion, who have no contact with on-site investigators. Medication is packaged in opaque white bottles, each containing five soft gel capsules of the active drug or matching placebo, corresponding to complete individual treatment. Treatment codes are kept under the pharmacist responsibility, and all researchers are unaware of them. NUMBERS TO BE RANDOMISED (SAMPLE SIZE): The first stage is planned to include 200 patients (100 per group), the second stage is planned to include 1064 additional patients. The total sample size is 1264 patients. TRIAL STATUS: Currently the protocol version is the number 1.4 (from October 13th, 2020). The recruitment is ongoing since August 11th, 2020, and the first subject was enrolled on August 14th. Since then, 21 sites located in four provinces of Argentina were initiated, and 167 patients were recruited by January 11th, 2021. We anticipate to finish the recruitment for the first stage in mid-February, 2021, and in August, 2021 for the second stage. TRIAL REGISTRATION: The study protocol is registered in ClinicalTrials.gov (identifier number NCT04411446 ) on June 2, 2020. FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol. The study protocol has been reported in accordance with the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines (Additional file 2).

Association Between Vitamin D Deficiency and COVID-19 Incidence, Complications, and Mortality in 46 Countries: An Ecological Study.

Each patient's immune defenses play a major role in mitigating the impact (ie, morbidity and mortality) of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for coronavirus disease 2019 (COVID-19). Vitamin D is an important modulator of the immune system. Although serum 25-hydroxyvitamin D levels can be raised through diet or supplements, most vitamin D in the body is the result of dermal synthesis from ultraviolet radiation. The production of vitamin D in the skin, however, can be limited by latitude, skin-covering clothes, the use of sunblock, and skin pigmentation. Vitamin D deficiency affects a high percentage of the world population. Serum 25-hydroxyvitamin D levels are suboptimal, not only in specific risk groups but also in adults from many countries. Low vitamin D levels, therefore, represent a risk factor for several different pathologies, including SAR-CoV-2. This study used an ecological design to assess the association between vitamin D deficiency and COVID-19 incidence, complications, and mortality across 46 countries. All data were obtained from published sources. The results of the study suggest an association at the population level between the prevalence of vitamin D deficiency and the risk of being infected with COVID-19, severity of the disease, and risk of dying from it.

[Concerns and demands regarding COVID-19. Survey of health personnel]. / Preocupaciones y demandas frente a COVID-19. Encuesta al personal de salud.

The COVID-19 pandemic affected the organization of health services and had consequences for health teams, according to the pre-existing safety and working conditions. During the first week of April 2020, a cross sectional study was carried out with a qualitative-quantitative approach. The aim was to explore the conditions determining the organizational climate: leadership, communication, institutional resources, cohesion/conflict management, and training; and how these were perceived by health personnel to deal with the pandemic. A total of 5670 healthcare workers participated in an online survey and 50 were interviewed, from all subsectors of the Argentinean health system (public, private and union-health insurance); 72.9% were women, 51.4% were physicians, and the predominant age group was under 40 years. In the qualitative sample (interviews), 52% were men, 62% were physicians, and the average age was 44.8 years. The dimensions of the organizational climate were stratified and five independent predictors of perception of conditions were identified: age, gender, tasks performed, health system subsector, and jurisdiction. The condition most frequently perceived as inadequate were the inaccessibility of institutional resources and the access to personal protective equipment was a major concern. Claims included the need of institutional strategies to support healthcare workers and of a clear and uniform communication. In conclusion, at the time of the study, the health personnel perceived serious deficits in their organizations regarding the conditions necessary to confront COVID-19, with differences among subsectors of the health system.

La pandemia por COVID-19 afectó la organización de los servicios de salud y tuvo consecuencias en los equipos de salud, según las condiciones laborales y de bioseguridad pre-existentes en cada institución. Durante la primera semana de abril de 2020 se realizó un estudio de corte transversal. El objetivo fue indagar acerca de las condiciones que determinan el clima organizacional: liderazgo, comunicación, recursos institucionales, cohesión/gestión de conflictos y capacitación; y cómo éstas eran percibidas por el personal de salud para hacer frente a la pandemia. Se realizaron 5670 encuestas a trabajadores/as y 50 entrevistas a informantes clave de los tres subsectores del sistema de salud (público, privado y de seguridad social). En las encuestas, el 72.9% fueron mujeres, el 51.4% médicos/as y el grupo etario predominante fue el de menores de 40 años. El 47.8% de los/as participantes refirió pluriempleo. En las entrevistas, el 52% fueron varones, el 60% médicos/ as, la edad media 44.8 años. Se estratificaron las dimensiones y se identificaron predictores independientes de percepción: edad, género, tipo de tareas, subsector y jurisdicción. La dimensión percibida con mayor frecuencia como inadecuada fue la de recursos institucionales y la disponibilidad de equipos de protección personal fue identificada como una de las principales preocupaciones. Surgieron demandas de estrategias de contención para el personal de salud y de comunicación institucional clara y uniforme. En conclusión, al momento del estudio el personal de salud percibía serios déficits en sus organizaciones respecto de las condiciones necesarias para enfrentar la pandemia, con diferencias entre subsectores del sistema.

Multicap to improve adherence after acute coronary syndromes: results of a randomized controlled clinical trial.

BACKGROUND: Adherence to treatment after a myocardial infarction (MI) is poor, even in the early postinfarction period. Combining evidence-based drugs into a multicap could improve adherence in this population. No previous randomized trial assessing fixed-dose combination therapy has included patients early after a MI. We aimed to assess if a multicap containing four secondary prevention drugs increases adherence to treatment at 6 months after MI hospitalization. The study was designed as a randomized, parallel, open-label, controlled trial. METHODS: Patients were randomized within 7 days of a MI to either multicap or control group. The multicap group received a capsule containing aspirin, atenolol, ramipril, and simvastatin. The control group received each drug in separate pills. The primary outcome was adherence at 6 months. We also measured blood pressure, heart rate, serum cholesterol levels, C-reactive protein, and platelet aggregation. RESULTS: The study was stopped prematurely when 100 patients were included for futility. At 6 months, 92 (95.8%) patients were adherent to medical treatment: 98.0% in the multicap group and 93.5% in the control group [relative risk (RR) 1.05; 95% confidence interval (CI) 0.96-1.14; p = 0.347]. There were no differences between groups in systolic blood pressure (p = 0.662), diastolic blood pressure (p = 0.784), heart rate (p = 0.533), total cholesterol (p = 0.760), LDL-c (p = 0.979), C-reactive protein (p = 0.399), or in the proportion of patients with adequate platelet aggregation inhibition (p = 0.600). CONCLUSIONS: The study did not find any improvement in the adherence at 6 months after a MI with a multicap-based strategy (Multicap for Increase Adherence After Acute Myocardial Infarction; [ ClinicalTrials.gov identifier: NCT02271178]).

Síndrome post COVID-19. Gravedad y evolución en 4673 trabajadores sanitarios / Post COVID-19 syndrome. Severity and evolution in 4673 health care workers

Resumen Introducción : La evolución del síndrome post COVID ha sido variable y carecemos de información sobre su impacto en los profesionales de la salud. Métodos : Realizamos una encuesta a través de una red social en profesionales de la salud sobre casos de síndrome post COVID-19 confirmados con PCR. En un cuestionario web, preguntamos sobre 21 síntomas, su gravedad, duración, grado de afectación de la actividad y reincorporación al trabajo. Resultados : Respondieron 4673 profesionales sanita rios de 21 países, edad media de 47 años, 64% mujeres. El curso inicial fue asintomático en el 9%, síntomas leves en el 36%, síntomas moderados sin hospitalización en el 40% o con hospitalización en el 11%, y síntomas graves en el 1%. Los síntomas más prevalentes fueron fatiga (67%), insomnio (44%), ansiedad (42%), mialgia (41%) y anosmia (41%). La prevalencia se redujo a la mitad en los primeros 5 cinco meses, pero en muchos casos se prolongó durante más de un año. En el análisis multi variado los síntomas tendieron a agruparse en clusters (cognitivos, neuropsiquiátricos, cardiorrespiratorios, digestivos, otros). La necesidad de cambiar de área de trabajo fue del 16% y la falta de reincorporación al tra bajo del 7%, relacionadas con la mayor edad, el número de síntomas y la gravedad del curso inicial. Conclusión : En muchos casos la persistencia de los síntomas post COVID-19 puede ser prolongada y te ner un impacto laboral en los profesionales sanitarios, requiriendo la adopción de políticas específicas para reducir el daño.

Abstract Background : The evolution of post COVID-19 syn drome has been variable and we lack information on its impact on healthcare professionals. Methods : We conducted a survey through a social network in health professionals on post COVID-19 syn drome cases confirmed with PCR. In a web-based ques tionnaire, we asked about 21 symptoms, their severity, duration, degree of activity impairment and return to work. Results : 4673 health professionals from 21 countries responded, mean age of 47 years, 64% women. The initial course was asymptomatic in 9%, mild symptoms 36%, moderate symptoms without hospitalization 40% or with hospitalization 11%, and severe symptoms 1%. The most prevalent symptoms were fatigue (67%), insomnia (44%), anxiety (42%), myalgia (41%) and anosmia (41%). Prevalence dropped by half in the first 5 five months, but in many cases, it lasted for more than a year. In the mul 670 tivariate analysis, symptoms tended to be grouped into clusters (cognitive, neuropsychiatric, cardiorespiratory, digestive, others). The need to change the work area was 16% and lack of return to work 7%, related to older age, number of symptoms and severity of the initial course. Conclusion : in many cases the persistence of post- COVID symptoms can be prolonged and have an occu pational impact on healthcare professionals, requiring the adoption of specific policies to reduce harm.

Preocupaciones y demandas frente a COVID-19: Encuesta al personal de salud / Concerns and demands regarding COVID-19. Survey of health personnel

La pandemia por COVID-19 afectó la organización de los servicios de salud y tuvo consecuencias en los equipos de salud, según las condiciones laborales y de bioseguridad pre-existentes en cada institución. Durante la primera semana de abril de 2020 se realizó un estudio de corte transversal. El objetivo fue indagar acerca de las condiciones que determinan el clima organizacional: liderazgo, comunicación, recursos institucionales, cohesión/gestión de conflictos y capacitación; y cómo éstas eran percibidas por el personal de salud para hacer frente a la pandemia. Se realizaron 5670 encuestas a trabajadores/as y 50 entrevistas a informantes clave de los tres subsectores del sistema de salud (público, privado y de seguridad social). En las encuestas, el 72.9% fueron mujeres, el 51.4% médicos/as y el grupo etario predominante fue el de menores de 40 años. El 47.8% de los/as participantes refirió pluriempleo. En las entrevistas, el 52% fueron varones, el 60% médicos/ as, la edad media 44.8 años. Se estratificaron las dimensiones y se identificaron predictores independientes de percepción: edad, género, tipo de tareas, subsector y jurisdicción. La dimensión percibida con mayor frecuencia como inadecuada fue la de recursos institucionales y la disponibilidad de equipos de protección personal fue identificada como una de las principales preocupaciones. Surgieron demandas de estrategias de contención para el personal de salud y de comunicación institucional clara y uniforme. En conclusión, al momento del estudio el personal de salud percibía serios déficits en sus organizaciones respecto de las condiciones necesarias para enfrentar la pandemia, con diferencias entre subsectores del sistema.

The COVID-19 pandemic affected the organization of health services and had consequences for health teams, according to the pre-existing safety and working conditions. During the first week of April 2020, a cross sectional study was carried out with a qualitative-quantitative approach. The aim was to explore the conditions determining the organizational climate: leadership, communication, institutional resources, cohesion/conflict management, and training; and how these were perceived by health personnel to deal with the pandemic. A total of 5670 healthcare workers participated in an online survey and 50 were interviewed, from all subsectors of the Argentinean health system (public, private and union-health insurance); 72.9% were women, 51.4% were physicians, and the predominant age group was under 40 years. In the qualitative sample (interviews), 52% were men, 62% were physicians, and the average age was 44.8 years. The dimensions of the organizational climate were stratified and five independent predictors of perception of conditions were identified: age, gender, tasks performed, health system subsector, and jurisdiction. The condition most frequently perceived as inadequate were the inaccessibility of institutional resources and the access to personal protective equipment was a major concern. Claims included the need of institutional strategies to support healthcare workers and of a clear and uniform communication. In conclusion, at the time of the study, the health personnel perceived serious deficits in their organizations regarding the conditions necessary to confront COVID-19, with differences among subsectors of the health system.

[Association between biochemical markers and left ventricular dysfunction in the ST-elevation acute myocardial infarction]. / Asociación entre marcadores bioquímicos y disfunción ventricular izquierda en infarto con elevación del segmento ST.

OBJECTIVE: The association between biochemical markers and left ventricular ejection fraction in patients with myocardial infarction was not completely studied. Our goal is to study the association between biochemical markers and left ventricular dysfunction in patients with ST-elevation acute myocardial infarction. METHODS: With an observational and prospective design we included patients with less than 24h ST-elevation myocardial infarction. Leukocytes, glucose, B-type natriuretic peptide and T troponin were measured at admission, and creatine-phosphokinase and creatine-phosphokinase-MB were measured at admission and serially, and correlated with the ejection fraction estimated by echocardiography. RESULTS: A total of 108 patients were included. The median left ventricular ejection fraction was 48% (interquartile range 41-57). Simple linear regression analysis showed that B-type natriuretic peptide (P=.005), peak creatine-phosphokinase-MB (P=.01), leukocyte count (P=.001) and glucose (P=.033) were inversely and significantly associated with the left ventricular ejection fraction. The other parameters showed no association. B-type natriuretic peptide (P=.01) and peak creatine-phosphokinase-MB (P=.02) were the only two variables significantly associated with the left ventricular ejection fraction in the multiple linear regression analysis. Both markers were significantly associated with a left ventricular ejection fraction < 50%, independently of other clinical variables. CONCLUSION: B-type natriuretic peptide and peak creatine-phosphokinase-MB showed significant association with left ventricular ejection fraction in the acute phase of ST elevation acute myocardial infarction. This association was independent of the presence of other biochemical markers and clinical variables related to ventricular dysfunction.

Relato de experiencia: Grupo de monitoreo del plan estratégico de un hospital público en Argentina / An Account of Experience: A Strategic Plan Monitori ng Group at a Public Hospital in Argentina

INTRODUCCIÓN:El presente artículo comparte la experiencia de un trabajo llevado a cabo en relación a la planificación estratégica y su monitoreo en las reuniones del Grupo de Monitoreo del Plan Estratégico del "Hospital El Cruce, Alta complejidad en Red, Néstor Kirchner", de gestión pública, en Argentina. MÉTODOS: Es un estudio descriptivo que registra la dinámica y las actividades que el Grupo llevó a cabo: inicialmente abocadas a la medición y el reporte, para después pasar a convertirse en una herramienta de gestión, planificación estratégica, indicadores, Programas Operativos Anuales, estrechando lazos en ámbitos de salud entre la gestión y lo asistencial. CONCLUSIONES:El conjunto de acciones representa un insumo para generar un cambio organizacional basado en un registro continuo, análisis sistemático para poder concluir en toma de decisiones basadas en las prácticas y hechos reales.

INTRODUCTION:This article shares the experience of the strategic planning work and its monitoring in the meetings of the Strategic Plan Monitoring Group at the publicly managed El Cruce, Néstor Kirchner Hospital in a high-complexity network in Argentina. METHODS: It is a descriptive study that records the dynamics and the activities performed by the Group: initially devoted to measuring and reporting, then it turned into a management and strategic planning tool, with indicators, Annual Operative Programs and strengthening links between management and health care in health settings. CONCLUSIONS: This set of actions represents a resource aimed at generating an organizational change based on an ongoing recording and systematic analysis to finally allow for the decision-making on the basis of practice and real facts.

Referral and counter-referral system between secondary and tertiary care facilities in a children's hospital network of Greater Buenos Aires.

INTRODUCTION: Hospital El Cruce is a tertiary care facility which is part of a healthcare network that has been operating since July 2008 and includes health centers from five municipalities of the South of Greater Buenos Aires. The objective of the study was to describe the referral and counter-referral system at the pediatric intermediate medical care unit of the Hospital El Cruce, the tertiary level care of the network, and secondly to identify the critical points that could go against the consolidation of the network and to analyze the level of knowledge about it. POPULATION AND METHODS: This was a cross-sectional, prospective study conducted at the pediatric intermediate medical care unit of Hospital El Cruce between July 2008 and December 2010. Indicators related to patient admission and discharge were analyzed. A survey was administered to all the heads of the network's pediatric departments in order to assess the level of knowledge they had about it. RESULTS: A total of1677patients were hospitalized; 83.9% were referred from the network. Of all referrals made, 71.1% were accepted. There were 156 patients (9.4%) who were counter-referred to the referring facility. The survey results showed that 70% of heads of pediatric departments were unaware of the range of services provided by the network. CONCLUSIONS: Health care exchange was predominantly based on accepting patients referred from secondary care facilities to Hospital El Cruce and a minimum number of counter-referrals to referring facilities, with a radial pattern dynamics. There was scarce knowledge about the availability of the network health service delivery.

Análisis de traslados interhospitalarios de pacientes críticos a área de unidad coronaria de un hospital de alta complejidad

Introducción: Los traslados interhospitalarios de pacientes críticos son frecuentes en nuestro medio; sin embargo, a pesar de la existencia de servicios de traslados médicos de emergencia tanto en el ámbito público como privado, no se han generado publicaciones científicas relacionadas con traslado de pacientes críticos que permitan conocer su funcionamiento, planificación y resultados. Objetivo: Describir las condiciones de traslado interhospitalario de pacientes con patología cardiovascular. Material y métodos: Estudio de diseño observacional, prospectivo, multicéntrico. Se relevaron los traslados interhospitalarios por vía terrestre de pacientes ingresados a una unidad coronaria de tercer nivel entre abril de 2014 y abril de 2015. Se encuestó al médico de traslado. Se relevaron además las complicaciones relacionadas con el traslado y la mortalidad hospitalaria. Resultados: Se analizaron 214 traslados. Mediana de tiempo de traslado: 30 minutos (IIC 18,5-50). El 16,1% de los traslados se consideraron de riesgo alto, el 71,2% de riesgo moderado y el 12,7% de riesgo bajo, según un puntaje validado. Los principales diagnósticos fueron síndrome coronario agudo (66,8%), insuficiencia cardíaca (8,9%) y bradiarritmia o bloqueo (3,7%). El 73,5% de los traslados de riesgo alto se realizaron con móviles de alta complejidad y entre los de riesgo bajo y moderado, el 30,8% y el 28,9%, respectivamente, se efectuaron con móviles de baja complejidad. El 50% de los traslados fueron realizados por médicos residentes. El 10,8% presentaron alguna complicación durante el traslado y/o durante la primera hora. Las complicaciones fueron más frecuentes en traslados de riesgo alto y se asociaron con mortalidad hospitalaria. No existió asociación entre mayor riesgo de traslado estimado y mayor complejidad del móvil (p = 0,6). Conclusión: La programación de traslados no fue adecuada. El riesgo calculado de los traslados fue predominantemente bajo, con una elevada proporción de complicaciones graves, que impactaron en la mortalidad hospitalaria.