Approach to cardiology residents clinical aptitude evaluation. Multicenter design.

INTRODUCTION: To the best of our knowledge, the research herein presented is the first multicenter study in Mexico to analyze the development of clinical aptitude in medical units that train cardiologists. OBJECTIVE: To determine the degree of development of clinical aptitude in cardiology residents at three High Specialty Medical Units. METHODS: Multicenter, cross-sectional design. All students of the 2019-2020 academic year were included in the study. An instrument was constructed that evaluated clinical aptitude based on eight indicators and 170 items; conceptual/content validity and reliability were assessed by five cardiologists with teaching and educational research experience. RESULTS: By indicator and year of residence, significant statistical differences were observed in the CMN20Nov academic site. At HCSXXI and INCICh, statistically significant differences were observed in one of eight indicators. Differences between R1 residents (n = 41) of all three academic sites were estimated by indicator, with statistical significance being recorded in three of eight indicators. Between R2 (n = 35) and between R3 residents (n = 43), the result was similar. CONCLUSIONS: The degree of clinical aptitude development can be considered intermediate in all three academic sites, probably because the instrument explored problematized clinical situations that required for the residents to critically reflect on their clinical experience.

INTRODUCCIÓN: Hasta donde se tiene conocimiento, la investigación que se presenta constituye el primer trabajo multicéntrico en México que estudia el desarrollo de la aptitud clínica en unidades formadoras de cardiólogos. OBJETIVO: Determinar el grado de desarrollo de la aptitud clínica en residentes de cardiología en tres unidades médicas de alta especialidad. MÉTODOS: Diseño transversal multicéntrico. Se analizaron todos los estudiantes del ciclo académico 2019-2020. Se construyó un instrumento que evaluó la aptitud clínica a partir de ocho indicadores y 170 ítems; la validez conceptual/de contenido y la confiabilidad fueron valoradas por cinco cardiólogos con experiencia docente y en investigación educativa. RESULTADOS: Por indicador y año de residencia se observaron diferencias estadísticas significativas en la sede CMN20Nov; en HCSXXI e INCICh se observaron diferencias estadísticamente significativas en uno de ocho indicadores. Se estimaron diferencias entre residentes R1 (n = 41) de las tres sedes por indicador, con significación estadística en tres de ocho indicadores. El resultado fue semejante al comparar R2 (n = 35) y R3 (n = 43). CONCLUSIONES: El grado de desarrollo de la aptitud clínica se puede considerar medio en las tres sedes académicas, probablemente debido a que el instrumento exploró situaciones clínicas problematizadas que exigieron del residente la reflexión crítica de su experiencia clínica.

External validation of the natriuretic response prediction equation to discriminate diuretic response in heart failure.

AIMS: Incomplete decongestion due to lack of titration of diuretics to effective doses is a common reason for readmission in patients with acute decompensated heart failure (ADHF). The natriuretic response prediction equation (NRPE) is a novel tool that proved to be rapid and accurate to predict natriuretic response and does not need urine collection. However, the NRPE has not been externally validated. The goal of this study was to externally validate the discrimination capacity of the NRPE in patients with ADHF and fluid overload. METHODS AND RESULTS: Patients admitted with ADHF who required intravenous loop diuretics were included. A spot urine sample was obtained ~2 h following diuretic administration, and a timed 6-h urine collection by study staff was carried out. Urine sodium and urine creatinine from the spot urine sample were used to predict the 6-h natriuretic response using the NRPE. The primary goal was to validate the NRPE to discriminate poor loop diuretic natriuretic response (sodium output <50 mmol in the 6 h following diuretic administration). The NRPE was compared with urine sodium and measured urine output which are the methods currently recommended by international guidelines to assess diuretic response. Eighty-seven diuretic administrations from 49 patients were analysed. Mean age of patients was 57 ± 17 years and 67% were male. Mean estimated glomerular filtration rate was 65 ± 28 mL/min/1.73 m2, and ejection fraction was 35 ± 15%. Median dose of intravenous furosemide equivalents administered the day of the study was 80 mg (IQR 40 - 160). Poor natriuretic response occurred in 39% of the visits. The AUC of the NRPE to predict poor natriuretic response during the 6-h urine collection was 0.91 (95% CI 0.85-0.98). Compared with the NRPE, spot urine sodium concentration (AUC 0.75) and urine output during the corresponding nursing shift (AUC 0.74) showed lower discrimination capacity. CONCLUSIONS: In this cohort of patients with ADHF, the NRPE outperformed spot urine sodium concentration and all other metrics related to diuretic response to predict poor natriuretic response. Our findings support the use of this equation at other settings to allow rapid and accurate prediction of natriuretic response.

Obesity and Hyperandrogenemia in Polycystic Ovary Syndrome: Clinical Implications.

Polycystic ovary syndrome (PCOS) is often accompanied with metabolic disturbances attributed to androgen excess and obesity, but the contribution of each has not been defined, and the occurrence of metabolic disturbances is usually not investigated. Ninety-nine women with PCOS and forty-one without PCOS were evaluated. The clinical biomarkers of alterations related to glucose (glucose, insulin, and clamp-derived glucose disposal - M), liver (aspartate aminotransferase, alanine aminotransferase, and gamma-glutamyl transferase), and endothelium (arginine, asymmetric dymethylarginine, carotid intima-media thickness, and flow-mediated dilation) metabolism were measured; participants were categorized into four groups according to their obesity (OB) and hyperandrogenemia (HA) status as follows: Healthy (no-HA, lean), HA (HA, lean), OB (no-HA, OB), and HAOB (HA, OB). Metabolic disturbances were very frequent in women with PCOS (≈70%). BMI correlated with all biomarkers, whereas free testosterone (FT) correlated with only glucose- and liver-related indicators. Although insulin sensitivity and liver enzymes were associated with FT, women with obesity showed lower M (coef = 8.56 - 0.080(FT) - 3.71(Ob); p < 0.001) and higher aspartate aminotransferase (coef = 26.27 + 0.532 (FT) + 8.08 (Ob); p = 0.015) than lean women with the same level of FT. Women with obesity showed a higher risk of metabolic disorders than lean women, independent of hyperandrogenemia. Clinicians are compelled to look for metabolic alterations in women with PCOS. Obesity should be treated in all cases, but hyperandrogenemia should also be monitored in those with glucose-or liver-related disturbances.

Sodium restriction in patients with chronic heart failure and reduced ejection fraction: A randomized controlled trial.

BACKGROUND: Sodium restriction is recommended for patients with heart failure (HF) despite the lack of solid clinical evidence from randomized controlled trials. Whether or not sodium restrictions provide beneficial cardiac effects is not known. METHODS: The present study is a randomized, double-blind, controlled trial of stable HF patients with ejection fraction ≤ 40%. Patients were allocated to sodium restriction (2 g of sodium/day) vs. control (3 g of sodium/day). The primary outcome was change in N-terminal pro-B-type natriuretic peptide (NT-proBNP) at 20 weeks. Secondary outcomes included quality of life and adverse safety events (HF readmission, blood pressure or electrolyte abnormalities). RESULTS: Seventy patients were enrolled. Median baseline sodium consumption was 3268 (2225-4537) mg/day. Adherence to the intervention based on 24-hour urinary sodium was 32%. NT-proBNP and quality of life did not significantly change between groups (p > 0.05 for both). Adverse safety events were not significantly different between the arms (p > 0.6 for all). In the per protocol analysis, patients who achieved a sodium intake < 2500 mg/day at the intervention conclusion showed improvements in NT-proBNP levels (between-group difference: -55%, 95% confidence interval -27 to -73%; p = 0.002) and quality of life (between-group difference: -11 ± 5 points; p = 0.04). Blood pressure decreased in patients with lower sodium intake (between-group difference: -9 ± 5 mmHg; p = 0.05) without significant differences in symptomatic hypotension or other safety events (p > 0.3 for all). CONCLUSIONS: Adherence assessed by 24-hour natriuresis and by the nutritionist was poor. The group allocated to sodium restriction did not show improvement in NT-proBNP. However, patients who achieved a sodium intake < 2500 mg/day appeared to have improvements in NT-proBNP and quality of life without any adverse safety signals. CLINICALTRIALS: gov Identifier: NCT03351283.

Citrulline supplementation improves spatial memory in a murine model for Alzheimer's disease.

OBJECTIVES: Alzheimer's disease (AD) correlates with the dysfunction of metabolic pathways that translates into neurological symptoms. An arginine deficiency, a precursor of nitric oxide (NO), has been reported for patients with AD. We aimed to evaluate the effect of citrulline oral supplementation on cognitive decline in an AD murine model. METHODS: Three-month citrulline or water supplementation was blindly given to male and female wild-type and 3 × Tg mice with AD trained and tested in the Morris water maze. Cerebrospinal fluid and brain tissue were collected. Ultra-performance liquid chromatography was used for arginine determinations and the Griess method for NO. RESULTS: Eight-month-old male 3 × Tg mice with AD supplemented with citrulline performed significantly better in the Morris water maze task. Arginine levels increased in the cerebrospinal fluid although no changes were seen in brain tissue and only a tendency of increase of NO was observed. CONCLUSIONS: Citrulline oral administration is a viable treatment for memory improvement in the early stages of AD, pointing to NO as a viable, efficient target for memory dysfunction in AD.

Failures of the Fontan System in Univentricular Hearts and Mortality Risk in Heart Transplantation: A Systematic Review and Meta-Analysis.

The Fontan procedure (FP) is the standard surgical treatment for Univentricular heart diseases. Over time, the Fontan system fails, leading to pathologies such as protein-losing enteropathy (PLE), plastic bronchitis (PB), and heart failure (HF). FP should be considered as a transitional step to the final treatment: heart transplantation (HT). This systematic review and meta-analysis aims to establish the risk of death following HT according to the presence of FP complications. There was a total of 691 transplanted patients in the 18 articles, immediate survival 88% (n = 448), survival from 1 to 5 years of 78% (n = 427) and survival from 5.1 to 10 years of 69% (n = 208), >10 years 61% (n = 109). The relative risk (RR) was 1.12 for PLE (95% confidence interval [CI] = 0.89-1.40, p = 0.34), 1.03 for HF (0.7-1.51, p = 0.88), 0.70 for Arrhythmias (0.39-1.24, p = 0.22), 0.46 for PB (0.08-2.72, p = 0.39), and 5.81 for CKD (1.70-19.88, p = 0.005). In patients with two or more failures, the RR was 1.94 (0.99-3.81, p = 0.05). After FP, the risk of death after HT is associated with CKD and with the presence of two or more failures.

[Risk stratified in the National Registry of Acute Coronary Syndromes at the IMSS]. / Riesgo estratificado de los síndromes coronarios agudos. Resultados del primer Renasca-IMSS.

OBJECTIVE: to identify prognostic factors in the National Registry of Acute Coronary Syndromes. METHODS: patients in medical care units with acute ischemic coronary syndrome (AICS) according to the criteria of the American Heart Association/American College of Cardiology/European Society of Cardiology, considering the GRACE score (GS) were studied. RESULTS: there were 2389 patients, 28.9 % women and 71.1 % men, mean age 63 ± 11.7 years; with AICS with ST-segment elevation (69.11 %) and 30.89 % with AICS without ST elevation. The average of GS was 168. A GS > 150 points in patients with AICS without ST elevation was associated with recurrent ischemia or angina (RR = 1.4, p = 0.05), left ventricular failure (RR = 3.1, p < 0.0001), stroke (RR = 2.9, p = 0.004) and arrhythmias (RR = 2.7, p < 0.0001). The patients with AICS with ST-segment elevation were associated with death (RR = 1.6, p = 0.01), reinfarction (RR = 1.7, p = 0.001), recurrent ischemia (RR = 1.2, p = 0.04), left ventricular failure (RR = 3.4, p < 0.001), stroke (RR = 3.9, p < 0.001) and arrhythmias (RR = 2.3, p < 0.001). Fibrinolytic therapy was used in 40.2 %. There was a negative correlation between GS and fibrinolytic therapy (r -0.04, p = 0.04). CONCLUSIONS: the AICS with ST-segment elevation is more frequent and have a high GS.

Evaluation of endothelial function and diastolic function in patients with primary hyperparathyroidism before and after parathyroidectomy.

INTRODUCTION: Primary hyperparathyroidism (PHPT) is the leading cause of outpatient hypercalcemia associated with increased cardiovascular risk. The flow-mediated vasodilation (FMV) has been proposed as a non-invasive method for assessing endothelial function. OBJECTIVE: To compare the endothelial dysfunction measured by FMV and diastolic dysfunction in patients with PHPT before and after parathyroidectomy. METHOD: We performed a quasi-experimental (before-after) study to evaluate diastolic function and FMV in patients with PHPT before and six months after parathyroidectomy. RESULTS: Fifteen patients completed study: 12 women and 3 men; 73% presented lithiasis, 27% osteoporosis and 53% metabolic syndrome; 73% presented diastolic dysfunction before the surgery and 60% after the surgery (p = 0.09). Post-isquemia brachial diameter improved from 41 mm (before surgery) to 46 mm (after surgery; p = 0.020). After surgery, we also observed an increase in the brachial diameter pre vs. post-ischemia from 41 to 46 mm (p = 0.005). Before surgery, the change in the delta of brachial diameter pre and post-ischemia was 1 mm and up to 4 mm after surgery (p = 0.03). CONCLUSIONS: There is a minor endothelial dysfunction measured by FMV in patients who underwent surgery for PHPT at 6 months after surgery, as well as a trend towards improvement in diastolic dysfunction. Echocardiography can be useful in the preoperative evaluation in patients with asymptomatic PHPT.

INTRODUCCIÓN: El hiperparatiroidismo primario (HPTP) es la principal causa de hipercalcemia ambulatoria y se ha asociado con un riesgo cardiovascular elevado. La vasodilatación mediada por flujo (VMF) es un método no invasivo que evalúa la función endotelial. OBJETIVO: Comparar la disfunción endotelial mediante VMF y la disfunción diastólica en pacientes con HPTP antes y después de la paratiroidectomía. MÉTODO: Mediante un estudio cuasiexperimental (antes-después) se evaluaron la función diastólica y la VMF antes y 6 meses después de realizar una paratiroidectomía. RESULTADOS: Se incluyeron 15 pacientes con HPTP: 12 mujeres (80%) y 3 hombres (20%); el 73% presentaron litiasis, el 27% osteoporosis y el 53% síndrome metabólico; el 73% tenían disfunción diastólica antes de la cirugía y el 60% después de la cirugía (p = 0.09). Los diámetros braquiales post-isquemia mejoraron de 41 mm antes de la cirugía a 46 mm tras la cirugía (p = 0.020). Así mismo, los diámetros braquiales preisquemia vs. post-isquemia después de la cirugía mejoraron de 41 a 46 mm (p = 0.005). Antes de la cirugía, el cambio en la delta del diámetro braquial preisquemia y post-isquemia fue de 1 mm, y subió a 4 mm después de la cirugía (p = 0.03). CONCLUSIONES: Existe una menor disfunción endotelial medida por VMF en pacientes posoperados por HPTP a los 6 meses de la cirugía. El estudio ecocardiográfico puede ser de utilidad en la evaluación preoperatoria de los pacientes con HPTP asintomáticos.

Right ventricular longitudinal strain predicts acute kidney injury and short-term prognosis in patients with right ventricular myocardial infarction.

Right ventricular (RV) systolic dysfunction due to acute myocardial infarction is associated with serious complications in the short-term. Acute kidney injury (AKI) is a frequent and unrecognized complication. This study aimed to assess whether RV longitudinal strain predicts AKI and short-term prognosis in patients with RV infarction. Prospective cohort of patients with RV infarction. RV function was evaluated with global and free wall right ventricular longitudinal strain (GRVLS and FWRVLS), tricuspid annular plane systolic excursion, and tricuspid S' wave. The primary endpoint was AKI defined as an increase ≥ 50% in serum creatinine and/or a decrease ≥ 25% in glomerular filtration rate during follow-up at 7 days. The secondary endpoint was death from any cause at 30 days. We included 101 patients with RV infarction (male 67%, age 66 ± 11 years). During follow-up at 7 days, 40% of patients developed AKI. At 30 days, 8% of patients died. At univariate analysis, FWRVLS was significantly associated with AKI (Hazard ratio [HR] 1.11, 95% confidence interval [CI] 1.03-1.20, p = 0.006). At multivariate analysis, only age, temporary pacemaker implant, and FWRVLS remained as independent predictors of AKI (HR 1.05, 95% CI 1.02-1.08, p = 0.002; HR 2.12, 95% CI 1.11-4.07, p = 0.023; HR 1.10, 95% CI 1.02-1.19, p = 0.018, respectively). At 30 days, patients with FWRVLS ≥ - 15.5% showed a lower survival rate than those with lower strain (84 ± 6 vs. 97 ± 2%, p = 0.021). In patients with RV infarction, FWRVLS was an independent predictor of AKI and was associated with higher mortality in the short-term.

Right atrial pressure predicts worsening renal function in patients with acute right ventricular myocardial infarction.

BACKGROUND: Right ventricular myocardial infarction (RVMI) is associated with serious complications in the short-term. Worsening renal function (WRF) is a frequent and dangerous complication. We investigated if right atrial pressure (RAP) predicts WRF in these patients. METHODS: We prospectively studied patients with RVMI. RAP was obtained invasively at admission to coronary care unit. Blood samples were extracted from patients at baseline and every 24h for creatinine measurements for seven days. We defined WRF as an increase of 25% or 0.5mg/dl in serum creatinine during the first seven days compared to baseline creatinine. RESULTS: We included forty-five patients (age 68±10years, male 71%). WRF occurred in 51%. The best cut-off value of RAP for WRF prediction was 11mmHg. RAP ≥11mmHg was associated with WRF at univariate analysis (OR 5.5, 95% CI 1.27-24.3, p=0.023) and multivariate analysis (OR 6.1, 95% CI 1.07-35.4, p=0.042). RAP ≥11mmHg improved reclassification and discrimination after usual prediction with the Mehran score (net reclassification improvement 64.8%, p=0.030; integrated discrimination improvement 7.5%, p=0.037). CONCLUSION: In patients with RVMI, RAP ≥11mmHg predicted WRF and improved discrimination.

Tei Index Is the Best Echocardiographic Parameter for Assessing Right Ventricle Function in Patients With Unrepaired Congenital Heart Diseases With Outflow Tract Obstruction.

Objective: Magnetic resonance imaging (MRI) and cardiac catheterization are diagnostic tools for right ventricle dysfunction (RVD), but those are expensive and often unavailable techniques. Thus, our objective was to identify clinical and/or echocardiographic variables capable of predicting a catheterization-based diagnosis of RVD. Design: This was cross-sectional, diagnostic test accuracy study, considering the catheterization-based diagnosis of RVD as the gold standard. Patients: Pediatric patients with non-repaired CHD with overload pressure were evaluated. Clinical variables (edema and functional class), transthoracic echocardiography (right heart dimensions, systolic and diastolic function, Doppler velocities), and cardiac catheterization (pressures and right ventricle systolic work measurements) were obtained during the same hospitalization. Results: We included 253 patients with tetralogy of Fallot (39.9%), pulmonary atresia with ventricular septal defect (33.9%), type C Ebstein's anomaly (15.8%), or pulmonary stenosis (10.4%). Among clinical (vascular congestion, functional class derangement) and echocardiographic (indexed right ventricle diameter, fractional area change, tricuspid annular plane systolic excursion, S' wave, Tei index) variables, the Tei index (defined as the ratio of isovolumetric contraction time to ejection time) was the sole variable that exhibited high diagnostic capability, with 98.5% sensitivity, 97.4% specificity, 97.8% positive predictive value, and 98.3% negative predictive value, with 98.0% overall performance. Multivariate logistic regression confirmed that Tei index alone predicted the catheterization-based diagnosis of RVD. Conclusions: Tei index is the best parameter that can be employed for the non-invasive identification of RVD in patients with CHD.

[Demographic analysis of a congenital heart disease clinic of the Mexican Institute of Social Security, with special interest in the adult]. / Análisis demográfico de una clínica de cardiopatías congénitas del Instituto Mexicano del Seguro Social, con interés en el adulto.

INTRODUCTION: Congenital heart disease (CHD) has an incidence of 8-10 cases per 1000 live births. In Mexico, there are 18,000-20,000 new cases per year. Most tertiary care centers for CHD attend only pediatric population; the Mexican Institute of Social Security (IMSS) has a clinic that attends pediatric and adult population. OBJECTIVE: To analyze the demographic aspects of the CHD clinic of IMSS. METHODS: From 2011 to 2016 a cross-sectional study of the CC clinic of a third level hospital of the IMSS, including all patients with confirmed structural heart disease of recent diagnosis was carried out. The sex, age, reference entity, antecedent of pregnancy and treatment were registered. The population was divided into age ranges (<2 years, 2.1-6 years, 6.1-10 years, 10.1-17 years and >17.1 years). Descriptive statistics and χ2 test were used in qualitative variables. RESULTS: 3,483 patients with CHD (male:female ratio, 0.8:1.2) were included. Increased pulmonary flow acyanogenic cardiopathies were the most frequent CHD group (47.2%), with atrial septal defect being the most frequent diagnosis overall; 25.6% were adults and 35% of women with a history of pregnancy. Chiapas was Federal entity with greater proportion of patients diagnosed in the adult stage (33.82%); 7% were not candidates for any treatment for complications of the disease. CONCLUSIONS: CHD is a late diagnosis; it is necessary to create a national register to promote new health policies and a rational distribution of resources for these patients.

[Acute myocardial infarction with ST-segment elevation: Code I]. / Infarto agudo del miocardio con elevación del segmento ST: Código I.

Code infarction is a timely strategy for the treatment of acute myocardial infarction (AMI) with elevation of the ST segment. This strategy has shown an increase in survival and quality of life of patients suffering from this event around the world. The processes of management and disposition aimed at the reduction of time for effective and timely reperfusion are undoubtedly a continuous challenge. In the Instituto Mexicano del Seguro Social (IMSS) the mortality due to AMI has been reduced more than 50%, which is a historical situation that deserves much attention. Nonetheless, the continuous improvement and a wider coverage of this strategy in our country are the key factors that will outline a change in the natural history of the leading cause of death in Mexico. This review focuses on current strategies for the management of patients with acute myocardial infarction.

Código Infarto es una estrategia de manejo oportuno del infarto agudo del miocardio (IAM) con elevación del segmento ST que ha demostrado en todo el mundo un incremento en la sobrevida y calidad de vida de los pacientes que sufren de este evento. Los procesos de gestión y atención oportuna dirigidos a la reducción de tiempo para la reperfusión eficaz y eficiente son sin duda un reto continuo. En el IMSS se ha logrado más del 50% de reducción en la mortalidad, situación histórica que merece mucha atención. Sin embargo, será la mejora continua y la generalización de los servicios a todo el país lo que demarcará un cambio en la historia natural de la primera causa de muerte en nuestro país. Esta revisión se centra en las estrategias actuales del manejo de pacientes con infarto agudo de miocardio.

Reduction of No Reflow with a Loading Dose of Atorvastatin before Primary Angioplasty in Patients with Acute ST Myocardial Infarction.

BACKGROUND: No reflow defined as an altered myocardial reperfusion and failure at microvascular level is a frequent complication in acute myocardial infarction that attenuates beneficial effect of reperfusion therapy leading to poor outcomes. There is not enough evidence to support that previous use of statins improves coronary flow in patients undergoing primary percutaneous coronary intervention (PCI). AIM OF STUDY: To determine if a loading dose of 80 mg of atorvastatin before primary angioplasty reduces the frequency of no reflow, hs-CRP, IL6 intracoronary levels, and major combined cardiovascular events at 30 d. METHODS: In this controlled clinical trial, we randomly assigned 103 adult patients within the 12 h of acute ST-elevation myocardial infarction (STEMI) to receive 80 mg of atorvastatin additional to standard treatment (AST) before performing primary PCI versus standard treatment (ST) alone. The primary outcomes were the occurrence of no reflow and high sensitivity C-reactive protein (hs-CRP) and interleukin 6 levels and secondary outcomes were major adverse cardiovascular events at 30 d. RESULTS: 103 patients were analyzed, 49 (48%) received AST, 54 (52%) ST. Frequency of no reflow among groups was 27 vs. 63% respectively, p ≤0.0001. hs-CRP level was 2.69 mg/dL for AST vs. 2.2 mg/dL in ST, meanwhile IL-6 levels were 5.2 pg/mL vs. 6.35 pg/mL respectively, p = ns. Cox regression model demonstrated that the treatment assigned is an independent predictor for no reflow occurrence (HR 0.34 95%, CI 0.18-0.61, p ≤0.001). CONCLUSION: The administration of a loading dose of 80 mg atorvastatin before primary PCI is an effective strategy for prevention of no reflow improving also clinical outcomes and free survival rate for the presentation of major adverse cardiovascular events at 30 d.

[Training of institutional research networks as a strategy of improvement]. / Formación de redes institucionales de investigación como una estrategia de mejora.

The Instituto Mexicano del Seguro Social (IMSS) through the Coordinación de Investigación en Salud (Health Research Council) has promoted a strong link between the generation of scientific knowledge and the clinical care through the program Redes Institucionales de Investigación (Institutional Research Network Program), whose main aim is to promote and generate collaborative research between clinical, basic, epidemiologic, educational, economic and health services researchers, seeking direct benefits for patients, as well as to generate a positive impact on institutional processes. All of these research lines have focused on high-priority health issues in Mexico. The IMSS internal structure, as well as the sufficient health services coverage, allows the integration of researchers at the three levels of health care into these networks. A few years after their creation, these networks have already generated significant results, and these are currently applied in the institutional regulations in diseases that represent a high burden to health care. Two examples are the National Health Care Program for Patients with Acute Myocardial Infarction "Código Infarto", and the Early Detection Program on Chronic Kidney Disease; another result is the generation of multiple scientific publications, and the promotion of training of human resources in research from the same members of our Research Networks. There is no doubt that the Coordinación de Investigación en Salud advances steadily implementing the translational research, which will keep being fruitful to the benefit of our patients, and of our own institution.

El Instituto Mexicano del Seguro Social (IMSS), a través de la Coordinación de Investigación en Salud, ha promovido el vínculo entre la generación de conocimiento científico y la actividad asistencial mediante el programa de Redes Institucionales de Investigación, cuyo objetivo principal es la promoción y generación de trabajo de investigación colaborativo entre investigadores del área clínica, básica, epidemiológica, educativa y en economía y sistemas de salud, buscando siempre obtener productos que tengan aplicación directa sobre los pacientes y generen un impacto positivo en los procesos institucionales. Todas las líneas de investigación se enfocan en los temas prioritarios de salud de México. La estructura interna del IMSS y la vasta cobertura de servicios que ofrece permiten incluir en estas redes a personal de los tres niveles de atención médica. A pocos años de su creación, estas redes han generado importantes resultados que se aplican en la normativa institucional en enfermedades con alta carga asistencial y económica; por ejemplo, el programa "Código Infarto" y el Programa de Detección Temprana de Enfermedad Renal Crónica; otro resultado son las múltiples publicaciones científicas y la promoción de la formación de recursos humanos en investigación de los mismos integrantes de nuestras redes de investigación. Sin duda, la Coordinación de Investigación en Salud avanza a grandes pasos en la implementación cada vez más sólida de la investigación traslacional, que seguirá dando frutos en beneficio de nuestros pacientes y de la propia institución.

Hypofibrinolytic State in Subjects with Type 2 Diabetes Mellitus Aggravated by the Metabolic Syndrome before Clinical Manifestations of Atherothrombotic Disease.

Background. Metabolic and genetic factors induce plasminogen activator inhibitor type-1 (PAI-1) overexpression; higher PAI-1 levels decrease fibrinolysis and promote atherothrombosis. Aim. To assess PAI-1 antigen levels among subjects with type 2 diabetes mellitus (T2DM) plus Metabolic Syndrome (MetS) before clinical manifestations of atherothrombosis and the contribution of metabolic factors and 4G/5G polymorphism of PAI-1 gene on the variability of PAI-1. Methods. We conducted an observational, cross-sectional assay in a hospital in Mexico City from May 2010 to September 2011. MetS was defined by the International Diabetes Federation criteria. PAI-1 levels and 4G/5G polymorphism were determined by ELISA and PCR-RFLP analysis. Results. We enrolled 215 subjects with T2DM plus MetS and 307 controls. Subjects with T2DM plus MetS had higher PAI-1 levels than the reference group (58.4 ± 21 versus 49.9 ± 16 ng/mL, p = 0.026). A model with components of MetS explained only 12% of variability on PAI-1 levels (R2 = 0.12; p = 0.001), with ß = 0.18 (p = 0.03) for hypertension, ß = -0.16 (p = 0.05) for NL HDL-c, and ß = 0.15 (p = 0.05) for NL triglycerides. Conclusion. Subjects with T2DM plus MetS have elevated PAI-1 levels before clinical manifestations of atherothrombotic disease. Metabolic factors have a more important contribution than 4G/5G polymorphism on PAI-1 plasma variability.

[Protocol for the care of acute myocardial infarction in emergency: Código infarto (The Infarction Code)]. / Protocolo para atención de infarto agudo de miocardio en urgencias: Código infarto.

Cardiovascular diseases are a major public health problem because of their they impact on more than 30% of all deaths worldwide. In our country and in the Instituto Mexicano del Seguro Social (IMSS) are also the leading cause of death and the main cause of lost of healthy life years due to disability or premature death. 50% of deaths are premature; most of them are due to acute myocardial infarct. However, the investment for cardiovascular health is poor and there are no comprehensive cares programs focused on the treatment of this diseases or the control of their risk factors. To address this problem, the first institutional care program was developed, called "A todo corazón", which aims to strengthen actions to promote healthy habits, prevention and care of cardiovascular diseases. The initial approach is to implement a protocol of care emergency services called "Código infarto", which is intended to ensure the diagnosis and treatment of patients demanding emergency care for acute myocardial infarction and receive reperfusion treatment with primary angioplasty in the first 90 minutes, or fibrinolytic therapy in the first 30 minutes after the admission to the IMSS emergency services.

Las enfermedades cardiovasculares son un problema de salud pública por su impacto en más del 30% de las muertes del mundo. En nuestro país y en el IMSS son también la primera causa de muerte y en años de vida saludable perdidos por muerte prematura o discapacidad. El 50% de las muertes son prematuras, y la mayor parte se deben a infarto agudo de miocardio. Sin embargo, sigue siendo pobre la inversión para la salud cardiovascular y no existen programas de atención integral enfocados al tratamiento de estas enfermedades ni para el control de los factores de riesgo. Ante esta problemática se desarrolló el primer programa de atención integral a nivel institucional llamado "A todo corazón", que pretende fortalecer las acciones para promoción de hábitos saludables, la prevención y atención de las enfermedades cardiovasculares. El enfoque inicial es implementar un protocolo de atención para los servicios de urgencias llamado "Código infarto", el cual pretende garantizar el diagnóstico y tratamiento del paciente que demanda atención de urgencias por infarto agudo de miocardio, de manera que pueda recibir tratamiento de reperfusión con angioplastía primaria en los primeros 90 minutos, o terapia fibrinolítica en los primeros 30 minutos posteriores a su ingreso a los servicios de urgencias del IMSS.

Aproximación hacia la evaluación de la aptitud clínica en residentes de cardiología. Diseño multicéntrico / Approach to cardiology residents clinical aptitude evaluation. Multicenter design

Resumen Introducción: Hasta donde se tiene conocimiento, la investigación que se presenta constituye el primer trabajo multicéntrico en México que estudia el desarrollo de la aptitud clínica en unidades formadoras de cardiólogos. Objetivo: Determinar el grado de desarrollo de la aptitud clínica en residentes de cardiología en tres unidades médicas de alta especialidad. Métodos: Diseño transversal multicéntrico. Se analizaron todos los estudiantes del ciclo académico 2019-2020. Se construyó un instrumento que evaluó la aptitud clínica a partir de ocho indicadores y 170 ítems; la validez conceptual/de contenido y la confiabilidad fueron valoradas por cinco cardiólogos con experiencia docente y en investigación educativa. Resultados: Por indicador y año de residencia se observaron diferencias estadísticas significativas en la sede CMN20Nov; en HCSXXI e INCICh se observaron diferencias estadísticamente significativas en uno de ocho indicadores. Se estimaron diferencias entre residentes R1 (n = 41) de las tres sedes por indicador, con significación estadística en tres de ocho indicadores. El resultado fue semejante al comparar R2 (n = 35) y R3 (n = 43). Conclusiones: El grado de desarrollo de la aptitud clínica se puede considerar medio en las tres sedes académicas, probablemente debido a que el instrumento exploró situaciones clínicas problematizadas que exigieron del residente la reflexión crítica de su experiencia clínica.

Abstract Introduction: To the best of our knowledge, the research herein presented is the first multicenter study in Mexico to analyze the development of clinical aptitude in medical units that train cardiologists. Objective: To determine the degree of development of clinical aptitude in cardiology residents at three High Specialty Medical Units. Methods: Multicenter, cross-sectional design. All students of the 2019-2020 academic year were included in the study. An instrument was constructed that evaluated clinical aptitude based on eight indicators and 170 items; conceptual/content validity and reliability were assessed by five cardiologists with teaching and educational research experience. Results: By indicator and year of residence, significant statistical differences were observed in the CMN20Nov academic site. At HCSXXI and INCICh, statistically significant differences were observed in one of eight indicators. Differences between R1 residents (n = 41) of all three academic sites were estimated by indicator, with statistical significance being recorded in three of eight indicators. Between R2 (n = 35) and between R3 residents (n = 43), the result was similar. Conclusions: The degree of clinical aptitude development can be considered intermediate in all three academic sites, probably because the instrument explored problematized clinical situations that required the residents to critically reflect on their clinical experience.

[Consensus on Systemic Arterial Hypertension In México]. / Consenso de Hipertensión Arterial Sistémica en México.

This Consenso Nacional de Hipertensión Arterial Sistémica (National Consensus on Systemic Arterial Hypertension) brings together experiences and joint work of 79 specialists who have been in contact with the patient affected by systemic arterial hypertension. All concepts here presented were outlined on the basis of the real world practice of Mexican hypertensive population. The consensus was developed under strict methodological guidelines. The Delphi technique was applied in two rounds for the development of an appropriate statistical analysis of the concepts exposed by all the specialists, who posed key questions, later developed by the panel of experts of the Hospital de Cardiología, and specialists from the Centro Médico Nacional. Several angles of this illness are shown: detection, diagnosis, pathophysiology, classification, treatment and prevention. The evidence analysis was carried out using PRISMA method. More than 600 articles were reviewed, leaving only the most representative in the references. This document concludes with practical and useful recommendations for the three levels of health care of our country.

Este Consenso Nacional de Hipertensión Arterial Sistémica reúne las experiencias y el trabajo conjunto de 79 especialistas que han estado en contacto con el paciente que padece hipertensión arterial sistémica. Todos los conceptos aquí presentados se plantearon con base en la práctica del mundo real de la población hipertensa de México. El consenso se desarrolló bajo lineamientos metodológicos estrictos. La técnica de Delphi se aplicó en dos vueltas para el desarrollo de un análisis estadístico apropiado de los conceptos vertidos por todos los especialistas con preguntas clave que desarrolló el panel de expertos del Hospital de Cardiología y especialistas del Centro Médico Nacional. Se presentan los aspectos de detección, diagnóstico, fisiopatología, clasificación, tratamiento y prevención. El análisis de la evidencia en la literatura se hizo utilizando el método de PRISMA para análisis de evidencia. Se revisaron más de 600 artículos y se dejaron en la bibliografía solo los más representativos. Este documento concluye con recomendaciones prácticas y de utilidad para los tres niveles de atención en salud de nuestro país.

[Network Research on Human Papillomavirus]. / Red de Investigación en Virus del Papiloma Humano.

In order to increase the research in important health questions at a national and institutional levels, the Human Papillomavirus Research Network of the Health Research Coordination of the Instituto Mexicano del Seguro Social offers this supplement with the purpose of assisting patients that daily look for attention due to the human papillomavirus or to cervical cancer.

A fin de incrementar la investigación en temas prioritarios de salud a nivel nacional e institucional, la Red de Investigación del Virus del Papiloma Humano de la Coordinación de Investigación en Salud del Instituto Mexicano del Seguro Social ofrece este suplemento con el objetivo de beneficiar a las pacientes que día a día se atienden por el virus de papiloma humano o por el cáncer cervicouterino.