Morphine and clinical outcomes in patients with ST segment elevation myocardial infarction treated with fibrinolytic and antiplatelet therapy: Insights from the TREAT trial.

BACKGROUND: Morphine is commonly used to relieve pain, anxiety and dyspnea in STEMI but it lowers blood pressure and delays the activity of oral antiplatelet agents. The impact of morphine on clinical outcomes remains unknown. This analysis was performed to determine if morphine use was associated with increased risk of adverse clinical events among STEMI patients treated with fibrinolytic therapy and clopidogrel or ticagrelor. METHODS: In the Ticagrelor in Patients with ST Elevation Myocardial Infarction Treated with Pharmacological Thrombolysis (TREAT) study, 3799 STEMI patients treated with fibrinolysis were randomized to receive clopidogrel or ticagrelor. Morphine use was left to the discretion of the treating physicians. In this pre-specified analysis, we evaluated clinical outcomes based on the use and timing of morphine administration. Outcomes were stratified by randomized treatment group. Multivariable analysis was performed using Inverse Probability Treatment Weighting (IPTW) weighting. RESULTS: Morphine was used in 53% of patients. After adjustment using IPTW weighting, morphine use was associated with higher hazard of reinfarction at 7 days (HR 4.9, P = .0006) and 30 days (HR 1.7, P = .04), and lower hazard of major bleeding (HR 0.37, P = .006). There was no significant difference in mortality at any time point. CONCLUSIONS: Among patients with STEMI treated with fibrinolytic therapy, morphine use was associated with a higher risk of early reinfarction and a lower risk of major bleeding but no difference in mortality. CLINICAL TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT02298088.

[The HEARTS app: a clinical tool for cardiovascular risk and hypertension management in primary health careO aplicativo HEARTS: uma ferramenta clínica para o gerenciamento de risco cardiovascular e hipertensão na atenção primária à saúde]. / La aplicación HEARTS: una herramienta clínica para el manejo del riesgo cardiovascular y la hipertensión en la atención primaria de salud.

HEARTS in the Americas is the regional adaptation of the World Health Organization's Global Hearts Initiative, which will be the model for risk management for cardiovascular disease (CVD) in primary health care in the Region of the Americas by 2025. It has already been implemented in 21 countries and 1045 primary health care centers throughout Latin America and the Caribbean. It takes a public health and health systems approach to systematically introduce simplified interventions at the primary health care level and focuses on hypertension as a clinical entry point. This paper introduces a new, improved application (app), the main component of which is the calculator for CVD risk and hypertension management. The paper summarizes the risk assessment approach and the methodology used by the World Health Organization to update its cardiovascular risk charts in 2019; describes the app, its use, functionality and validation process; and provides a set of practical recommendations for optimizing CVD risk and hypertension management by using the app in clinical practice. The HEARTS app is a powerful tool to improve the quality of care provided in primary health settings. The creation and dissemination of the HEARTS app is an essential step in the journey towards eliminating preventable CVD in the Americas.

HEARTS nas Américas é a adaptação regional da Iniciativa Global Hearts da Organização Mundial da Saúde, que será o modelo para o gerenciamento de risco de doenças cardiovasculares (DCV) na atenção primária à saúde na Região das Américas até 2025. Ele já foi implementado em 21 países e 1045 centros de saúde primária em toda a América Latina e Caribe. Adota uma abordagem de saúde pública e sistemas de saúde para introduzir sistematicamente intervenções simplificadas no nível da atenção primária à saúde e concentra-se na hipertensão como um ponto de entrada clínica. Este documento introduz uma nova e melhor aplicação (app), cujo principal componente é a calculadora de risco de DCV e gerenciamento de hipertensão. O artigo resume a abordagem de avaliação de risco e a metodologia usada pela Organização Mundial da Saúde para atualizar seus gráficos de risco cardiovascular em 2019; descreve o aplicativo, seu uso, funcionalidade e processo de validação; e fornece um conjunto de recomendações práticas para otimizar o gerenciamento do risco de DCV e da hipertensão, usando o aplicativo na prática clínica. O aplicativo HEARTS é uma ferramenta potente para melhorar a qualidade dos cuidados prestados em ambientes de saúde primária. A criação e disseminação do aplicativo HEARTS é um passo essencial para eliminar a DCV evitável nas Américas.

The HEARTS app: a clinical tool for cardiovascular risk and hypertension management in primary health care.

HEARTS in the Americas is the regional adaptation of the World Health Organization's Global Hearts Initiative, which will be the model for risk management for cardiovascular disease (CVD) in primary health care in the Region of the Americas by 2025. It has already been implemented in 21 countries and 1045 primary health care centers throughout Latin America and the Caribbean. It takes a public health and health systems approach to systematically introduce simplified interventions at the primary health care level and focuses on hypertension as a clinical entry point. This paper introduces a new, improved application (app), the main component of which is the calculator for CVD risk and hypertension management. The paper summarizes the risk assessment approach and the methodology used by the World Health Organization to update its cardiovascular risk charts in 2019; describes the app, its use, functionality and validation process; and provides a set of practical recommendations for optimizing CVD risk and hypertension management by using the app in clinical practice. The HEARTS app is a powerful tool to improve the quality of care provided in primary health settings. The creation and dissemination of the HEARTS app is an essential step in the journey towards eliminating preventable CVD in the Americas.

HEARTS en las Américas es la adaptación regional de la Iniciativa Global Hearts de la Organización Mundial de la Salud, que será el modelo para el manejo del riesgo de la enfermedad cardiovascular (ECV) en la atención primaria de la salud en la Región de las Américas para el año 2025. Ya se ha implementado en 21 países y 1045 centros de atención primaria de salud en toda América Latina y el Caribe. Adopta un enfoque de salud pública y sistemas de salud para introducir sistemáticamente intervenciones simplificadas en el nivel de atención primaria de salud y se centra en la hipertensión como punto de entrada clínico. En este artículo se presenta una aplicación (app) nueva y mejorada cuyo componente principal es la calculadora de riesgo de ECV y de manejo de la hipertensión. Se resume el enfoque de evaluación del riesgo y la metodología utilizada por la Organización Mundial de la Salud para actualizar sus tablas de riesgo cardiovascular en 2019; se describe la app, su uso, su funcionalidad y su proceso de validación; y se proporciona un conjunto de recomendaciones prácticas para optimizar el manejo del riesgo de ECV y de la hipertensión mediante el uso de la app en la práctica clínica. La app HEARTS es una herramienta robusta para mejorar la calidad de la atención prestada en los centros de atención primaria. La creación y difusión de la aplicación HEARTS es un paso esencial en el camino hacia la eliminación de la ECV prevenible en las Américas.

HEARTS nas Américas é a adaptação regional da Iniciativa Global Hearts da Organização Mundial da Saúde, que será o modelo para o gerenciamento de risco de doenças cardiovasculares (DCV) na atenção primária à saúde na Região das Américas até 2025. Ele já foi implementado em 21 países e 1045 centros de saúde primária em toda a América Latina e Caribe. Adota uma abordagem de saúde pública e sistemas de saúde para introduzir sistematicamente intervenções simplificadas no nível da atenção primária à saúde e concentra-se na hipertensão como um ponto de entrada clínica. Este documento introduz uma nova e melhor aplicação (app), cujo principal componente é a calculadora de risco de DCV e gerenciamento de hipertensão. O artigo resume a abordagem de avaliação de risco e a metodologia usada pela Organização Mundial da Saúde para atualizar seus gráficos de risco cardiovascular em 2019; descreve o aplicativo, seu uso, funcionalidade e processo de validação; e fornece um conjunto de recomendações práticas para otimizar o gerenciamento do risco de DCV e da hipertensão, usando o aplicativo na prática clínica. O aplicativo HEARTS é uma ferramenta potente para melhorar a qualidade dos cuidados prestados em ambientes de saúde primária. A criação e disseminação do aplicativo HEARTS é um passo essencial para eliminar a DCV evitável nas Américas.

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.

A multifaceted intervention to improve treatment with oral anticoagulants in atrial fibrillation (IMPACT-AF): an international, cluster-randomised trial.

BACKGROUND: Oral anticoagulation is underused in patients with atrial fibrillation. We assessed the impact of a multifaceted educational intervention, versus usual care, on oral anticoagulant use in patients with atrial fibrillation. METHODS: This study was a two-arm, prospective, international, cluster-randomised, controlled trial. Patients were included who had atrial fibrillation and an indication for oral anticoagulation. Clusters were randomised (1:1) to receive a quality improvement educational intervention (intervention group) or usual care (control group). Randomisation was carried out centrally, using the eClinicalOS electronic data capture system. The intervention involved education of providers and patients, with regular monitoring and feedback. The primary outcome was the change in the proportion of patients treated with oral anticoagulants from baseline assessment to evaluation at 1 year. The trial is registered at ClinicalTrials.gov, number NCT02082548. FINDINGS: 2281 patients from five countries (Argentina, n=343; Brazil, n=360; China, n=586; India, n=493; and Romania, n=499) were enrolled from 48 clusters between June 11, 2014, and Nov 13, 2016. Follow-up was at a median of 12·0 months (IQR 11·8-12·2). Oral anticoagulant use increased in the intervention group from 68% (804 of 1184 patients) at baseline to 80% (943 of 1184 patients) at 1 year (difference 12%), whereas in the control group it increased from 64% (703 of 1092 patients) at baseline to 67% (732 of 1092 patients) at 1 year (difference 3%). Absolute difference in the change between groups was 9·1% (95% CI 3·8-14·4); odds ratio of change in the use of oral anticoagulation between groups was 3·28 (95% CI 1·67-6·44; adjusted p value=0·0002). Kaplan-Meier estimates showed a reduction in the secondary outcome of stroke in the intervention versus control groups (HR 0·48, 95% CI 0·23-0·99; log-rank p value=0·0434). INTERPRETATION: A multifaceted and multilevel educational intervention, aimed to improve use of oral anticoagulation in patients with atrial fibrillation and at risk for stroke, resulted in a significant increase in the proportion of patients treated with oral anticoagulants. Such an intervention has the potential to improve stroke prevention around the world for patients with atrial fibrillation. FUNDING: Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, and Pfizer.

Ticagrelor versus clopidogrel after fibrinolytic therapy in patients with ST-elevation myocardial infarction: Rationale and design of the ticagrelor in patients with ST elevation myocardial infarction treated with thrombolysis (TREAT) trial.

BACKGROUND: The safety and efficacy of ticagrelor in patients with ST-elevation myocardial infarction (STEMI) treated with fibrinolytic therapy remain uncertain. OBJECTIVES: The primary objective of the TicagRElor in pAtients with ST elevation myocardial infarction treated with Thrombolysis (TREAT) trial is to evaluate the short-term safety of ticagrelor when compared with clopidogrel in STEMI patients treated with fibrinolytic therapy. Key secondary objectives are to assess the safety and efficacy of ticagrelor compared with clopidogrel at 12-months. DESIGN: The TREAT trial is a multicenter, randomized, phase III, Prospective randomized open blinded end-point (PROBE) study that enrolled 3,799 patients in 152 sites from 10 countries. Following administration of fibrinolytic therapy patients were randomized to a loading dose of ticagrelor 180 mg or clopidogrel 300 mg followed by a maintenance dose of ticagrelor 90 mg twice daily or clopidogrel 75 mg/day for 12-months. The primary outcome is the rate of TIMI major bleeding at 30-days and will be assessed for non-inferiority using an intention-to-treat analysis. Co-treatments include aspirin and anticoagulants. Other evidence based therapies are also recommended. Secondary efficacy outcome include a composite of death from vascular causes, myocardial infarction, stroke, severe recurrent ischemia, transient ischemic attack or other arterial thrombotic event. All-cause mortality as well as individual components of the combined efficacy endpoint will also be ascertained. SUMMARY: TREAT is an international randomized controlled trial comparing ticagrelor with clopidogrel in STEMI patients treated with fibrinolytic therapy. The results of this trial will inform clinical practice and international guidelines.

Regional differences in presentation and antithrombotic treatment of patients with atrial fibrillation: Baseline characteristics from a clustered randomized trial to IMProve treatment with AntiCoagulanTs in patients with atrial fibrillation (IMPACT-AF).

Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide. However, there are few contemporary comparative data on AF from middle-income countries. METHODS: Baseline characteristics of the IMPACT-AF trial were analyzed to assess regional differences in presentation and antithrombotic treatment of AF from 5 middle-income countries (Argentina, Brazil, China, India, and Romania) and factors associated with antithrombotic treatment prescription. RESULTS: IMPACT-AF enrolled 2281 patients (69 ± 11 years, 47% women) at 48 sites. Overall, 66% of patients were on anticoagulation at baseline, ranging from 38% in China to 91% in Brazil. The top 3 reasons for not prescribing an anticoagulant were patient preference/refusal (26%); concomitant antiplatelet therapy (15%); and risks outweighing the benefits, as assessed by the physician (13%). In a multivariable model, the most significant factors associated with prescription of oral anticoagulants were no prior major bleeding (odds ratio [OR] = 4.34; 95% CI = 2.22-8.33), no alcohol abuse (OR = 2.27; 95% CI = 1.12-4.55), and history of rheumatic valvular heart disease (OR = 2.10; 95% CI = 1.36-3.26), with a strong predictive accuracy (c statistic = 0.85), whereas the most significant factors associated with prescription of a combination of oral anticoagulants and antiplatelet drugs were prior coronary revascularization (OR = 5.10; 95% CI = 2.88-9.05), prior myocardial infarction (OR = 2.24; 95% CI = 1.38-3.63), and no alcohol abuse (OR = 2.22; 95% CI = 1.11-4.55), with a good predictive accuracy (c statistic = 0.76). CONCLUSIONS: IMPACT-AF provides contemporary data from 5 middle-income countries regarding antithrombotic treatment of AF. Lack of prior major bleeding and coronary revascularization were the most important factors associated with prescription of oral anticoagulants and their combination with antiplatelet drugs, respectively.

Mobile phone text messaging to improve medication adherence in secondary prevention of cardiovascular disease.

BACKGROUND: Worldwide at least 100 million people are thought to have prevalent cardiovascular disease (CVD). This population has a five times greater chance of suffering a recurrent cardiovascular event than people without known CVD. Secondary CVD prevention is defined as action aimed to reduce the probability of recurrence of such events. Drug interventions have been shown to be cost-effective in reducing this risk and are recommended in international guidelines. However, adherence to recommended treatments remains sub-optimal. In order to influence non-adherence, there is a need to develop scalable and cost-effective behaviour-change interventions. OBJECTIVES: To assess the effects of mobile phone text messaging in patients with established arterial occlusive events on adherence to treatment, fatal and non-fatal cardiovascular events, and adverse effects. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, the Conference Proceedings Citation Index - Science on Web of Science on 7 November 2016, and two clinical trial registers on 12 November 2016. We contacted authors of included studies for missing information and searched reference lists of relevant papers. We applied no language or date restrictions. SELECTION CRITERIA: We included randomised trials with at least 50% of the participants with established arterial occlusive events. We included trials investigating interventions using short message service (SMS) or multimedia messaging service (MMS) with the aim to improve adherence to medication for the secondary prevention of cardiovascular events. Eligible comparators were no intervention or other modes of communication. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. In addition, we attempted to contact all authors on how the SMS were developed. MAIN RESULTS: We included seven trials (reported in 13 reports) with 1310 participants randomised. Follow-up ranged from one month to 12 months. Due to heterogeneity in the methods, population and outcome measures, we were unable to conduct meta-analysis on these studies. All seven studies reported on adherence, but using different methods and scales. Six out of seven trials showed a beneficial effect of mobile phone text messaging for medication adherence. Dale 2015a, reported significantly greater medication adherence score in the intervention group (Mean Difference (MD) 0.58, 95% confidence interval (CI) 0.19 to 0.97; 123 participants randomised) at six months. Khonsari 2015 reported less adherence in the control group (Relative Risk (RR) 4.09, 95% CI 1.82 to 9.18; 62 participants randomised) at eight weeks. Pandey 2014 (34 participants randomised) assessed medication adherence through self-reported logs with 90% adherence in the intervention group compared to 70% in the control group at 12 months. Park 2014a (90 participants randomised) reported a greater increase of the medication adherence score in the control group, but also measured adherence with an event monitoring system for a number of medications with adherence levels ranging from 84.1% adherence to 86.2% in the intervention group and 79.7% to 85.7% in the control group at 30 days. Quilici 2013, reported reduced odds of non-adherence in the intervention group (Odds Ratio (OR) 0.43, 95% CI 0.22 to 0.86, 521 participants randomised) at 30 days. Fang 2016, reported that participants given SMS alone had reduced odds of being non-adherent compared to telephone reminders (OR 0.40 95% CI 0.18 to 0.63; 280 patients randomised). Kamal 2015 reported higher levels of adherence in the intervention arm (adjusted MD 0.54, 95% CI 0.22 to 0.85; 200 participants randomised). Khonsari 2015 was the only study to report fatal cardiovascular events and only reported two events, both in the control arm. No study reported on the other primary outcomes. No study reported repetitive thumb injury or road traffic crashes or other adverse events that were related to the intervention.Four authors replied to our questionnaire on SMS development. No study reported examining causes of non-adherence or provided SMS tailored to individual patient characteristics.The included studies were small, heterogeneous and included participants recruited directly after acute events. All studies were assessed as having high risk of bias across at least one domain. Most of the studies came from high-income countries, with two studies conducted in an upper middle-income country (China, Malaysia), and one study from a lower middle-income country (Pakistan). The quality of the evidence was found to be very low. There was no obvious conflicts of interest from authors, although only two declared their funding. AUTHORS' CONCLUSIONS: While the results of this systematic review are promising, there is insufficient evidence to draw conclusions on the effectiveness of text message-based interventions for adherence to medications for secondary prevention of CVD. Sufficiently powered, high-quality randomised trials are needed, particularly in low- and middle-income countries.

Initial Results and Long-Term Follow-up of Percutaneous Mitral Valvuloplasty in Patients with Pulmonary Hypertension.

BACKGROUND: Percutaneous balloon mitral valvuloplasty (PMV) is an attractive therapeutic approach in patients with mitral stenosis. The aim of this study was to assess the immediate and long-term clinical, echocardiographic and haemodynamic outcomes of PMV in patients with severe pulmonary hypertension (PAH). METHODS: Percutaneous balloon mitral valvuloplasty was performed in 157 consecutive patients; 60 patients (38.2%) had significant PAH defined as baseline pulmonary artery mean pressure (PAMP) ≥ 30mm Hg (Group 1) and 97 patients (61.8%) had PAMP ≤ 30mmHg (Group 2). Pulmonary artery systolic pressure (PASP), mortality, need for mitral valve replacement or new PMV, and valve restenosis were evaluated during follow-up. RESULTS: Mean age was 44.2 years and 88.5% (139 patients) were women. Primary success was achieved in 79.6% of the patients (125 patients) without differences between the groups. Mitral valve area increased from 0.90cm2 to 1.76cm2, PASP fell from 57mmHg to 35mmHg in Group 1 and from 38mmHg to 30mmHg in Group 2. Median PASP in Group 1 was 35, 32, 36, 38 and 34mmHg at 12, 24, 36, 48 and 60 months. There were no significant differences in mitral valve area, PASP and clinical status between the groups. CONCLUSION: Percutaneous balloon mitral valvuloplasty is a safe and effective technique for the treatment of patients with mitral stenosis and PAH. A significant decrease in pulmonary pressure was observed after valvuloplasty. Although there was a gradual decrease of MVA at long-term follow-up, most patients remained asymptomatic and PASP was stable.

A clustered randomized trial to IMProve treatment with AntiCoagulanTs in patients with Atrial Fibrillation (IMPACT-AF): design and rationale.

Atrial fibrillation (AF) is common, increasing as the population ages, and a major cause of embolic stroke. While oral anticoagulation (OAC) is highly effective at preventing stroke in patients with AF, it continues to be underused in eligible patients worldwide. The objective of this prospective, cluster randomized controlled trial (IMPACT-AF; ClinicalTrials.gov #NCT02082548) is to determine whether a comprehensive customized intervention will increase the rate and persistence of use of OAC in patients with AF. IMPACT-AF will be conducted in approximately 50 centers in 5 low- to middle-income countries. Before randomization, sites within countries will be paired to match in size, practice type and baseline rate of OAC use. Site pairs will be randomized to intervention versus control. In total, 40 to 70 patients with AF and at least 2 CHA2DS2-VASc risk factors will be enrolled at each site using a consecutive enrollment strategy, with the goal of capturing actual practice patterns. We aim for patients with a new diagnosis of AF to comprise at least 30% of the study cohort. Assuming an average baseline OAC use of 60% and a post-intervention use of 70% with a post-control rate of 60%, there will be roughly 94-98% power with 25 clusters per group (intracluster correlation coefficient of 0.02). While this trial focuses on improving treatment use and reducing preventable strokes, we also aim to better understand the reasons for OAC underuse. This will improve the intervention with the goal of creating educational recommendations to improve care for patients with AF.

Disseminating cardiovascular disease risk assessment with a PAHO mobile app: a public eHealth intervention.

Cardiovascular diseases are the leading cause of death in the Region of the Americas, making cardiovascular risk assessment a critical component of the clinical decision-making process. This process is facilitated by the use of appropriate tools. This article presents the technical characteristics of an application (app) developed by the Pan American Health Organization/World Health Organization (PAHO/WHO) for mobile devices and computers. Called the Cardiovascular Risk Calculator, it is based on WHO risk tables and applied to the countries of the Region. The article details the epidemiological basis of the diagram for predicting cardiovascular risk and describes the app and its four modules, its main audiences, its production process, and finally, the initial results and some of the challenges. Four months after its launch, the application was being used daily by more than 12 000 users and had been downloaded in virtually all the countries of the Region. The app can be used in by physicians, nurses, and other technical personnel in their daily practice, especially at the primary care level. Since it can also be used by the general public, special attention was paid to its design and tutorial and to ensuring that the clinical estimates and recommendations were easy to understand. This type of app facilitates communication between health care providers and users, and its systematic use in the health services, especially in primary care services, should be promoted.

[Assaults on professionals in healthcare settings]. / Agresiones hacia profesionales en el ámbito de la salud.

OBJECTIVE: Determine the frequency of assaults on health workers and characterize aspects that deepen understanding and development of prevention strategies. METHODS: A voluntary and confidential electronic survey was conducted through the IntraMed website, a social network of health professionals. Frequency of verbal and physical assaults was analyzed along with their association with demographic variables, occupation, career, specialty, potential consequences, perception of insecurity in the workplace, and proposals to reduce them. RESULTS: A total of 19 967 surveys were analyzed, of which 13 323 (66.7%) described assaults. Assaults were physical in 11.3% of cases, and 73.4% occurred in public institutions, mainly in emergency areas. Delay in care and lack of resources were the most frequent triggers. Alcohol or drug intoxication was reported in 13.8% of aggressors, altered mental status from another cause or psychiatric illness in 13.9%, and no detected impairment of mental faculties in 63%. Of professionals attacked, 16.9% reported sequelae, 7.9% of which were physical, and 28% were temporarily unable to work. Insecurity in the workplace was described by 46.6% of respondents, who suggested various measures to reduce it, chief among them, community education CONCLUSIONS: Verbal and physical violence toward health workers was frequent, resulting in work-related, mental, and even physical sequelae. This study contributes information that could be used to develop strategies aimed at prevention and control of assaults.

Survey on Ethical Conduct Thresholds in Cardiologal Medical Practice in Argentina.

The purpose of this study was to analyze the attitude of a group of cardiologists on the ethical conducts they would accept or adopt when encountered with different hypothetical situations of medical practice. Between August and September of 2011, 700 Argentine cardiologists were surveyed in situations which posed ethical dilemmas in the patient-physician relationship, among colleagues or involving financial agreements with employers or the pharmaceutical industry. Ethical conflicts were evidenced in a series of inappropriate conducts such as differential fees, trips and meals sponsored by laboratories, splitting fees, overbilling, self-referral, charging for patient referral, financial compensation for ordering medical procedures, and various situations derived from the relationship with employers. In general, financial compensation from the pharmaceutical industry was more accepted than the conflictive situations which directly involved patients, colleagues or employers. The rejection of these conducts, the physicians' deontological education and the improvement of financial and organizational conditions in medical practice will help to encourage better medical professionalism and avoid unseemly behaviors.

[Heart failure due to arteriovenous fistula for hemodialysis. Presentation of two clinical cases]. / Insuficiencia cardíaca por fístula arteriovenosa para hemodiálisis. Presentación de dos casos clínicos.

Arteriovenous fistulas for hemodialysis create a leftto-right shunt, resulting in an average 25% increase in cardiac output and subsequent remodeling of cardiac chambers. Some of these patients may develop highoutput heart failure. In this report, we present two cases of heart failure associated with an arteriovenous fistula for hemodialysis, each showing distinct clinical outcomes following either its occlusion or cerclage. Drawing from existing medical literature, we explore potential causes that might account for the divergent clinical courses observed in these cases.

Las fístulas arteriovenosas para hemodiálisis generan un cortocircuito de izquierda a derecha con un incremento promedio en el gasto cardíaco del 25%, asociado a remodelado de las cavidades cardíacas. Un porcentaje de estos pacientes desarrollan insuficiencia cardíaca con alto gasto cardíaco. Presentamos dos casos de insuficiencia cardíaca asociada a fístula arteriovenosa para hemodiálisis, con diferente evolución clínica luego de la oclusión o cerclaje de la misma. Basados en la literatura médica, se discuten las potenciales causas que pudieron justificar las diferencias en la evolución clínica entre ambos casos.

Analysis of long COVID in health personnel: comparing gender and work factors.

INTRODUCTION: This study aimed to describe the reported prevalence of post-COVID-19 syndrome and its characteristics by gender, profession, and other determinants among health care workers. METHODS: A cross-sectional study was conducted among health workers with a history of COVID-19 in Latin America, and the 2030 responses from Argentina were selected for this analysis. Sociodemographic information, as well as data on initial course of COVID-19, and the persistence of 21 symptoms beyond the first month, their severity, clinical evolution, and health care demands were collected. RESULTS: The reported prevalence of post-COVID-19 syndrome was higher in women for each of the symptom clusters studied. Severity of the initial symptoms, female gender, nursing profession, multi-employment, and working in emergency areas were all independent variables. DISCUSSION: The greater strain of health care workers during the pandemic -highly feminized- and the associated gender conditions may partially explain these findings.

Introducción: El objetivo del estudio fue describir la prevalencia del reporte de síndrome post-COVID-19 y sus características según género, profesión y otros determinantes sociales, en personal de salud. Métodos: Se realizó un estudio de corte transversal en profesionales de salud con antecedentes de COVID-19 en América Latina, y para este análisis se seleccionaron las 2030 respuestas de Argentina. Se recolectaron datos sociodemográficos, información sobre el curso inicial de la enfermedad COVID-19, y persistencia de 21 síntomas más allá del primer mes, su gravedad, evolución clínica y requerimiento de servicios de salud. Resultados: Se identificó que la prevalencia reportada de síndrome post-COVID-19 fue mayor en mujeres para cada uno de los grupos de síntomas explorados. La gravedad del cuadro inicial, el género femenino, la profesión de enfermería, el multiempleo y trabajar en áreas de emergencia fueron variables independientes. Discusión: La mayor sobrecarga del personal de salud durante la pandemia ­altamente feminizado­ y las determinaciones de género asociadas podrían explicar parcialmente estos hallazgos.

[Diffusion and adoption of health care innovations in cardiology, in Argentina]. / Perfil de difusión y adopción de innovaciones de los cardiólogos en Argentina.

BACKGROUND: Medicine is changing rapidly and diagnostic and therapeutic innovations are common. Not all professionals adopt these innovations in the same way. AIM: To survey the physicians' opinions on adopting innovations in cardiovascular health care, to classify individuals from an innovative to a conservative behavior, and to individualize opinion leaders among them, in order to build a social network of influence. MATERIAL AND METHODS: Between November and December 2008, 765 Argentine cardiologists were surveyed via e-mail in Argentina, to assess the way they adopt and disseminate innovations in cardiovascular health care. RESULTS: The survey was answered by 537 professionals (70.2%). Fifty three percent of respondents were "Early adopters". However, 63 to 79.3% of respondents preferred to wait for a full demonstration of the usefulness of innovation before adopting it. The opinion leaders' distribution adopted a scale-free network pattern, where few leaders had many connections and influence on the whole network. The giant component of the network included 41% of physicians; growth simulation of the network showed that the four most popular leaders influenced over 44% of the giant component. CONCLUSIONS: Among surveyed physicians there was an attitude towards rapid acceptance of innovations in health care. However, when analyzing the direct opinion of physicians, most cases preferred usefulness demonstrated before accepting innovations. The social network including respondents and opinion leaders showed a scale-free topology with a big influence of a few over the whole network.

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.

Determinants of the clinical presentation of acute coronary syndromes.

INTRODUCTION: Two clinical presentations of acute coronary syndrome (ACS) have been defined: ST- segment elevation ACS (STEACS) or non-ST-segment elevation ACS (NSTEACS). The mechanism that determines the clinical presentation of ACS is not clearly understood. The aim of this study was to define the association between cardiovascular risk factors and other clinical variables with the clinical presentation of ACS as STEACS or NSTEACS. METHODS: We analyzed data of patients prospectively included in the Epi-Cardio Registry with a diagnosis of ACS from April 2006 to April 2018. A total of 10 019 patients were included in the study. RESULTS: In the multivariate analysis, male sex (OR 1.5) and active smoking (OR 1.71) were positively associated with STEACS presentation. Conversely, hypertension (OR 0.71), dyslipidemia (OR 0.74), age (OR 0.97 per quintile), history of myocardial infarction (OR 0.57), chronic angina (OR 0.44), presence of comorbidities (OR 0.64), and extension of coronary heart disease (OR 0.84) were negatively associated with STEACS. Women differed from men by presenting a higher incidence of NSTEACS, due to a greater proportion of ACS without obstructive coronary heart disease. CONCLUSION: Some cardiovascular risk factors and other clinical variables are independently associated with the presentation of ACS as ST EACS or NSTEACS. These findings confirm the influence of risk factors and clinical history on the pathophysiology, clinical and electrocardiographic presentation of ACS.

Introducción: Existen dos formas de presentación clínica de los síndromes coronarios agudos (SCA): con elevación del segmento ST (SCACEST) y sin elevación (SCASEST). Los mecanismos que determinan ambas presentaciones no se conocen completamente. El objetivo del estudio fue definir la asociación entre factores de riesgo cardiovascular y otras variables clínicas con la presentación de los SCA como SCACEST o SCASEST. Métodos: Analizamos información de pacientes incluidos prospectivamente en el Registro Epi-Cardio con diagnóstico de SCA desde abril de 2006 a abril de 2018.Se incluyeron un total de 10 019 pacientes. Resultados: En el análisis multivariado, el sexo masculino (OR 1.5) y el tabaquismo activo (OR 1.71) se asociaron positivamente con el SCACEST. Contrariamente, la hipertensión (OR 0.71), las dislipidemias (OR 0.74), la edad (OR 0.97 por quintilo), historia de infarto (OR 0.57), angina crónica (OR 0.44), presencia de comorbilidades (OR 0.64), y la extensión de enfermedad coronaria (OR 0.84) se asociaron negativamente con el SCACEST. Las mujeres presentaron mayor incidencia de SCASEST, debido a una mayor proporción de SCA sin obstrucción coronaria significativa. Conclusión: Concluimos que algunos factores de riesgo cardiovascular y otras variables clínicas se asociaron independientemente con la presentación clínica como SCACEST o SCASEST, confirmando su influencia en la fisiopatología y en la presentación clínica y electrocardiográfica de los SCA.