Update process ofthe National Agenda for Public Health Research 2021-2022 / Proceso de actualización de la agenda nacional de investigación en salud pública 2021-2022

RESUMEN INTRODUCCIÓN : Una Agenda Nacional de Investigación en Salud Pública (ANISP) participativa y con priorización temática constituye un elemento estratégico para generar recomendaciones y políticas públicas basadas en evidencia, que imparten positivamente en la salud de las poblaciones y permitan lograr los objetivos sanitarios. En la actualización de la ANISP participaron la Dirección de Investigación en Salud (DIS) del Ministerio de Salud de la Nación (MSAL), a través de la Red Ministerial de Investigación en Salud (REMINSA), y actores de los niveles gubernamentales provinciales y nacionales pertenecientes a los sectores público, privado, de la salud, académico y de investigación. Se adaptó la herramienta original propuesta por la Organización Panamericana de la Salud, utilizada en el proceso en 2019. La actualización abarcó diferentes etapas. La selección de los temas contó con la legitimidad, reconocimiento y participación de los actores vinculados a la salud, a la gestión gubernamental y privada y a la investigación científica; se trabajó de manera federal y transversal, por consenso con las redes provinciales y un Comité Central Asesor en el MSAL. A partir de los lineamientos preliminares obtenidos, se elaboró una encuesta en línea semiestructurada, que fue distribuida a todos los actores federales y recibió 431 respuestas. El proceso resultó en 55 lineamientos priorizados, divididos en 6 áreas temáticas y 33 subtemas, seleccionados por votación según importancia, impacto y factibilidad.

ABSTRACT INTRODUCTION : A participatory National Public Health Research Agenda (ANISP) with thematic prioritization is a strategic element to generóte evidence-based recommendations and public policies that have a positive impact on the health of populations and enable to achieve health objectives. The Directorate of Health Research (DIS) ofthe Argentine Ministry of Health (MSAL), through the Ministerial NetWork of Health Research (REMINSA), along with adors from the provincial and national government levels belonging to public, privóte, health, academic and research sectors participated in the update of the ANISP. They adapted the original tooI proposed by the Pan American Health Organizatlon and used in the process in 2019. The update included different stages. The selection ofthe topics had the legitimacy, recognition and participation ofthe actors involved, related to health, to government and privóte management and to scientific research; the work was conducted in a federal and transversal manner by consensus with the provincial networks and a Central Advisory Committee in the MSAL. Based on the preliminary guidelines obtained, a semi-structured online survey was developed and distributed to all federal actors, receiving 431 responses. The process resulted in 55 priorilized guidelines, divided into 6 thematic oreas and 33 sub-themes, selected by voting according to importance, impact and feasibility.

Proceso de actualización de la Agenda Nacional de Investigación Salud Pública 2021-2022 / Update process of the National Agenda for Public Health Research 2021-2022

INTRODUCCIÓN: Una Agenda Nacional de Investigación en Salud Pública (ANISP) participativa y con priorización temática constituye un elemento estratégico para generar recomendaciones y políticas públicas basadas en evidencia, que impacten positivamente en la salud de las poblaciones y permitan lograr los objetivos sanitarios. En la actualización de la ANISP participaron la Dirección de Investigación en Salud (DIS) del Ministerio de Salud de la Nación (MSAL), a través de la Red Ministerial de Investigación en Salud (REMINSA), y actores de los niveles gubernamentales provinciales y nacionales pertenecientes a los sectores público, privado, de la salud, académico y de investigación. Se adaptó la herramienta original propuesta por la Organización Panamericana de la Salud, utilizada en el proceso en 2019. La actualización abarcó diferentes etapas. La selección de los temas contó con la legitimidad, reconocimiento y participación de los actores vinculados a la salud, a la gestión gubernamental y privada y a la investigación científica; se trabajó de manera federal y transversal, por consenso con las redes provinciales y un Comité Central Asesor en el MSAL. A partir de los lineamientos preliminares obtenidos, se elaboró una encuesta en línea semiestructurada, que fue distribuida a todos los actores federales y recibió 431 respuestas. El proceso resultó en 55 lineamientos priorizados, divididos en 6 áreas temáticas y 33 subtemas, seleccionados por votación según importancia, impacto y factibilidad

Supervivencia de adultos hospitalizados con COVID-19 Y remdesivir reanálisis Bayesiano y metaanálisis de dos ensayos clínicos / Survival of adults hospitalized with COVID-19 and remdesivir: Bayesian re-analysis and meta-analysis of two clinical trials

INTRODUCCIÓN: entre los numerosos tratamientos evaluados contra la COVID-19, se encuentra el remdesivir, para el cual no se ha reportado efecto sobre la mortalidad. El objetivo de esta revisión es evaluar el efecto del remdesivir sobre la mortalidad en los primeros 28 días en pacientes hospitalizados por COVID-19. MÉTODOS: se efectuó una revisión en PubMed. Se seleccionaron solo los ensayos con asignación aleatoria que reportaron mortalidad a 28 días. El efecto del tratamiento se evaluó mediante un modelo bayesiano de efecto fijo y calculando la distribución posterior del riesgo relativo (RR) y el hazard ratio (HR). RESULTADOS: se encontraron dos ensayos clínicos que cumplieron los criterios de selección. La probabilidad de un RR combinado menor a 1 a favor de remdesivir para la mortalidad a 14 días fue de 98 %, con un intervalo de credibilidad de mayor densidad del 95% (ICrMD95% de 0,42-0,91) mientras que, mediante el reanálisis del estudio Adaptive COVID-19 Treatment Trial (ACTT-1) de Beigel et al., la probabilidad de un HR menor a 1 a favor de remdesivir fue de 96 %, con un ICrMD95% de 0,44-0,99. CONCLUSIONES: tanto el metaanálisis como el reanálisis bayesiano apoyan la existencia de un efecto favorable del tratamiento con remdesivir sobre la mortalidad de pacientes con neumonía por COVID-19

The potential of ecosystem-based management to integrate biodiversity conservation and ecosystem service provision in aquatic ecosystems.

Global aquatic biodiversity keeps declining rapidly, despite international efforts providing a variety of policies and legislations that identify goals for, and give directions to protecting the world's aquatic fauna and flora. With the H2020 project AQUACROSS, we have made an unprecedented effort to unify policy strategies, knowledge, and management concepts of freshwater, coastal, and marine ecosystems to support the achievement of the targets set by the EU Biodiversity Strategy to 2020. AQUACROSS has embraced the concept of ecosystem-based management (EBM), which approaches environmental management from a social-ecological system perspective to protect biodiversity and to sustainably harvest ecosystem services. This special issue includes contributions resulting from AQUACROSS, which either tackle selected EBM challenges from a theoretical point of view or apply EBM in one of the selected case studies across Europe. In this article, we introduce relevant topics, address the most important lessons learnt, and suggest where research should go with aquatic EBM. We hope that this special issue will foster and facilitate the uptake of EBM in aquatic ecosystems and, therewith, provide the on-ground applications needed for evaluating EBM's utility to safeguard aquatic biodiversity.

Protecting aquatic biodiversity in Europe: How much do EU environmental policies support ecosystem-based management?

The sustainable management of aquatic ecosystems requires better coordination between policies span-ning freshwater, coastal and marine environments. Ecosystem-based management (EBM) has been promoted as a holistic and integrative approach for the safekeeping and protection of aquatic biodiversity. The paper assesses the degree to which key European environmental policies for the aquatic environment, namely the Birds and Habitats Directives, Water Framework Directive and Marine Strategy Framework Directive, individually support EBM and can work synergistically to implement EBM. This assessment is based on a review of legal texts, EU guidance and implementation documents. The paper concludes that EBM can be made operational by implementing these key environmental directives. Opportunities for improving the integration of EU environmental policies are highlighted.

Evaluación del desempeño del programa de tutorías “IDEAS PROYECTO” del ministerio de salud de Argentina / Performance evaluation of mentoring program “ideas proyecto”, national ministry of health, Argentina

INTRODUCCIÓN: argentina ha evidenciado desde hace varios años una desigualdad entre los profesionales de lasdistintas jurisdicciones en el acceso a las becas de investigación quefinancia el Ministerio de Salud de la Nación. Debido a ello se haimplementado el programa de tutorías “Ideas Proyecto”, a travésdel cual se asiste metodológicamente a investigadores noveles enla formulación de proyectos a fin de mejorar la calidad y reducirla inequidad en el acceso a las becas Salud Investiga. OBJETIVOS: Evaluar la efectividad del programa para la obtención de una beca,así como la opinión y satisfacción de los participantes. MÉTODOS: La efectividad del programa se evaluó mediante un modelo bayesianojerárquico y la satisfacción mediante una encuesta auto administrada. RESULTADOS: Se registraron 2172 postulaciones a becas, de lascuales 40 fueron tutoradas. La tutoría aumentó la chance de obteneruna beca. La comprensibilidad de la información proporcionada por el tutor y la valoración general de la experiencia con la tutoría fueron los ítems con mayor valoración positiva (97%), mientras quela percepción de mejora del posicionamiento laboral fue el de mayor valoración negativa (24%). Los obstaculizadores y facilitadores másmencionados fueron la dosificación y el rol del tutor, respectivamente. CONCLUSIONES: Los resultados demuestran la eficacia de la tutoría para el logro de los objetivos del programa. La satisfacción positiva,los factores obstaculizadores y los factores facilitadores hallados permitirán mejorar el diseño e implementación del programa.

INTRODUCTION: argentina has shown for several years an inequality among professionals in the various jurisdictions in access to research grants that the National Ministry of Health finances. Because of that a mentoring program, “Ideas Proyecto”, was implemented, which assists methodologically junior researchers in the formulation of projects to improve quality and reduce inequality in access to Salud Investiga health research grants. OBJECTIVES: To evaluate the effectiveness of the program to obtain a scholarship as well as the opinion and satisfaction of participants. METHODS: The effectiveness of the program was assessed using a Bayesian hierarchical model and the satisfaction through a self-administered survey. RESULTS: A total of 2 172 scholarship applications were recorded, of which 40 were tutored. Mentoring increased the chance of getting ascholarship. The comprehensibility of the information providedby the tutor and the overall assessment of the experience withtutoring were the items with the most positive assessment (97%), while the perception of improvement in labor positioning had the most negative assessment (24%). The most mentioned hindering and facilitating factors were dosage and role of tutor,respectively. CONCLUSIONS: The results show the effectiveness of mentoring for achieving the program objectives. Positive satisfaction, hindering factors and facilitating factors found will help improve the design and implementation of the program.

Short-term amiodarone therapy after reversion of persistent atrial fibrillation reduces recurrences at 18 months.

BACKGROUND: The aim of this study was to compare the outcome of 3 months vs. 18 months of amiodarone treatment after atrial fibrillation (AF) conversion in patients who experienced the first episode of persistent AF. METHODS: We included 51 patients who experienced the first episode of persistent AF receiving amiodarone (600 mg) daily for 4-6 weeks. If AF persisted, electrical cardioversion (ECV) was performed. All patients received amiodarone (200 mg daily) for 3 months and then were randomized to amiodarone (Group I) or placebo (Group II) and followed for 15 months. The control group comprised 9 untreated patients undergoing ECV. Treatment effectiveness was evaluated using a Bayesian model. RESULTS: Eighteen months after AF reversion, 22 (81.5%) patients in Group I, 13 (54.2%) patients in Group II, and 1 (11.1%) patient in the control group remained in sinus rhythm. No differences were found between Group I patients who required ECV and Group II patients. Sinus rhythm was preserved in all Group I patients when it was achieved during amiodarone administration. Limiting adverse effects occurred in 3 (11.1%) patients in Group I. CONCLUSIONS: In patients regaining sinus rhythm after the first episode of persistent AF, a 3-month amiodarone treatment after reversion is a reasonable option for rhythm control.

Smoke-free environments: age, sex, and educational disparity in 25 Argentinean cities.

BACKGROUND: There is scarce evidence of secondhand smoke (SHS) and disparity in developing countries. We evaluated the relationship between socio-demographic variables and secondhand smoke-related factors in Argentina. METHODS: We conducted a randomized telephone survey (2008/2009) in 25 Argentinean cities. We included a sample of 160 respondents per city stratified by sex and age. We used different generalized multivariate regression models with a confidence interval of 95 % for the five outcome variables. RESULTS: We sampled 4,000 respondents, 52.2 % women, 36 % adolescents and young adults (15-29 years), 58 % ≥12 years of education, and 72.6 % nonsmokers. Support to 100 % smoke-free environment legislation was higher in older than in younger respondents, OR = 1.5 (IC: 1.2-2.0), and in people with higher education levels, OR = 1.2 (IC: 1.1-1.4). Exposure to SHS was significantly lower in men than in women at home and in public places, IRR = 0.7 (IC: 0.5-0.9) and IRR  = 0.8 (IC: 0.6-0.9), respectively. Older respondents reported lower exposure at home and in public places than adolescents and young adults, IRR = 0.6 (IC: 0.4-0.8) and IRR = 0.4 (IC: 0.3-0.5), respectively. People with higher education levels had a higher level of exposure in indoor public places than less educated people, IRR = 1.1 (IC: 1.1-1.2). Knowledge of respiratory disease in children caused by SHS exposure was lower in men than in women, RRR = 0.3 (IC: 0.1-0.6). Perceived compliance was higher in men than in women, OR = 1.4 (IC: 1.1-1.8) and in people with higher education levels, OR = 1.2 (IC: 1.1-1.4). Older and more educated respondents were more empowered than. younger and less educated people, OR = 1.5 (IC: 1.2-1.9) and OR = 1.2 (IC: 1.1-1.3), respectively. Reference groups for each variable were age: 15-29; education: ≤7 years; and sex: men. CONCLUSIONS: This is the first study to explore socio-demographic variables regarding secondhand smoke in our country. Women and younger people are more vulnerable to SHS-related factors in Argentina.

Integrating economic and biophysical data in assessing cost-effectiveness of buffer strip placement.

The European Union Water Framework Directive (WFD) requires Member States to set water quality objectives and identify cost-effective mitigation measures to achieve "good status" in all waters. However, costs and effectiveness of measures vary both within and between catchments, depending on factors such as land use and topography. The aim of this study was to develop a cost-effectiveness analysis framework for integrating estimates of phosphorus (P) losses from land-based sources, potential abatement using riparian buffers, and the economic implications of buffers. Estimates of field-by-field P exports and routing were based on crop risk and field slope classes. Buffer P trapping efficiencies were based on literature metadata analysis. Costs of placing buffers were based on foregone farm gross margins. An integrated optimization model of cost minimization was developed and solved for different P reduction targets to the Rescobie Loch catchment in eastern Scotland. A target mean annual P load reduction of 376 kg to the loch to achieve good status was identified. Assuming all the riparian fields initially have the 2-m buffer strip required by the General Binding Rules (part of the WFD in Scotland), the model gave good predictions of P loads (345-481 kg P). The modeling results show that riparian buffers alone cannot achieve the required P load reduction (up to 54% P can be removed). In the medium P input scenario, average costs vary from £38 to £176 kg P at 10% and 54% P reduction, respectively. The framework demonstrates a useful tool for exploring cost-effective targeting of environmental measures.

Inappropriate sinus tachycardia may be related to an immunologic disorder involving cardiac beta andrenergic receptors.

BACKGROUND: The mechanisms underlying inappropriate sinus tachycardia are not fully known. An autonomic imbalance seems to play a role, but no attempts have been made to investigate a relationship between this arrhythmia and the antiautonomic membrane receptor antibodies found in other heart disorders and arrhythmias. OBJECTIVE: The purpose of this study was to investigate the prevalence and the functional and biochemical effects of circulating antiautonomic receptor antibodies in patients with inappropriate sinus tachycardia. METHODS: We studied 21 patients with inappropriate sinus tachycardia and 15 healthy volunteers. The chronotropic effects of the IgG fractions (also of affinity-purified anti-beta1 adrenergic receptor antibodies in selected cases) were assessed on cultured cardiomyocytes before and after exposure to atropine and propranolol. The effects of the IgG fractions from five patients and five healthy volunteers on cAMP production were evaluated in COS-7 cells transfected with genes encoding for beta1 or beta2 adrenergic receptor. RESULTS: The IgG fractions from patients with inappropriate sinus tachycardia exerted a positive chronotropic action with a high prevalence of anti-beta receptor antibodies (52%) and induced a clear-cut and long lasting increment of cAMP. No anti-M2 cholinergic receptor antibodies were found. The IgG fractions from healthy volunteers did not contain antiautonomic receptor antibodies. CONCLUSIONS: Our results suggest, for the first time, a link between inappropriate sinus tachycardia and circulating anti-beta adrenergic receptor antibodies that induce a persistent increment in cAMP production. This finding offers new insight into the physiopathology of inappropriate sinus tachycardia with potential therapeutic consequences.

Oscilaciones neuronales como mecanismo consciente: elementos para una discusión / Neuron oscillation as a conscious mechanism: some elements for discussion

Trabajos anteriores han demostrado la existencia de actividad eléctrica oscilatoria sincrónica en diversas porciones del sistema nervioso. Con el registro de su coherencia, esta actividad ha sido catalogada como una candidata para ser el sustrato neurobiológico de la conciencia humana. Aquí se explora la posibilidad de la existencia de un lenguaje temporal que represente los objetos de la cognición y, por tanto, de la conciencia humana.

Pharmacologic reversion of persistent atrial fibrillation with amiodarone predicts long-term sinus rhythm maintenance.

OBJECTIVE: The study analyzed the role of different variables that determine long-term sinus rhythm maintenance in patients with persistent atrial fibrillation who are treated with amiodarone. BACKGROUND: It has been recognized that different factors influence long-term sinus rhythm preservation after the conversion of persistent atrial fibrillation. Although the duration of the arrhythmia appears to be the most important factor, consistent information regarding the role of the mode of arrhythmia conversion (pharmacologic or electric) is still lacking. METHODS: One hundred and forty one anticoagulated patients with persistent atrial fibrillation (median duration 8 months, percentiles 25 and 75: 2-24) were treated for 4 weeks with oral amiodarone (600 mg/day). Those in whom the arrhythmia persisted underwent electric cardioversion. After restoration of normal sinus rhythm (either pharmacologic or electric), all patients received a daily dose of amiodarone (200 mg) and were followed for a median of 19 months (percentiles 25 and 75: 8-34 months). RESULTS: Sixty eight patients (48.22%) regained sinus rhythm during the initial period of amiodarone treatment with 600 mg/day (Group I) and 73 (51.78%) required electric cardioversion (Group II). During the entire follow-up, atrial fibrillation relapsed in 63 patients: 17 (25%) in Group I and 46 (63%) in Group II. Recurrences of the arrhythmia were strikingly less frequent in patients whose atrial fibrillation lasted 12 months or less (33/103, 32.3%) than in those whose atrial fibrillation lasted more than 12 months (30/38, 78.94%). In the multivariate analysis, the mode of reversion (HR, 0.37; CI, 0.21-0.65) and the duration of the arrhythmia (HR, 2.55; CI, 1.54-4.20) were the determinants for long-term sinus rhythm maintenance. Age, sex, left atrium size, left ventricle diameter, and the shortening fraction did not significantly influence the rate of arrhythmia recurrence. Among the 141 patients included in the study, 113 patients were followed for at least 1 year, and cardiac rhythm was assessed at this time. Of these, only 1 of 48 patients (2.1%) in Group I was in atrial fibrillation, in marked contrast with 18 of 65 patients (27.8%) in Group II (RR, 0.075; 95% CI, 0.01-0.54). CONCLUSIONS: In patients with persistent atrial fibrillation, long-term preservation of sinus rhythm under chronic amiodarone treatment may be anticipated when the arrhythmia lasts 12 months or less and/or its reversion is obtained pharmacologically. We may confidently assume that these two factors have a beneficial additive influence on the outcome.

Low urinary 6-sulfatoxymelatonin levels in patients with severe congestive heart failure.

OBJECTIVE: To assess urinary 6-sulfatoxymelatonin excretion in patients admitted to the hospital because of congestive heart failure (CHF). METHODS: Urinary 6-sulfatoxymelatonin was measured by a specific radioimmunoassay in 33 hospitalized patients with CHF and in 146 healthy ambulatory volunteers. Individuals with hepatic or renal failure were excluded from the sample. Data were analyzed by the Mann-Whitney test and regression analysis. RESULTS: 6-Sulfatoxymelatonin levels were significantly lower in CHF patients than controls (median 2.6 vs 6.02 microg, p < 0.0001). This decrease was observed regardless of beta-adrenergic blocker or benzodiazepine medication. A significant decrease in 6-sulfatoxymelatonin excretion occurred with age. There were no significant differences in urinary 6-sulfatoxymelatonin levels between chronic and acute CHF patients. CONCLUSIONS: The results suggest that circulating melatonin levels are low in patients with CHF. Such a decrease may precede aggravation of heart failure.

Infarto agudo de miocardio en una unidad de medicina intensiva del interior COMECA, 1988-1998 / Acute myocardial infarction in an Intensive Care Unit at the country interior COMECA, 1988-1998

En el período 1988-98 la mortalidad global por Infarto Agudo de Miocardio en la Unidad de Cuidados Intensivos de COMECA fue de un 15 por ciento. El análisis discriminado de la mortalidad permitió detectar grupos de alto riesgo y conductas a rever. Discriminada por gravedad al ingreso, la mortalidad se mantuvo en los cánones internacionales. Las mujeres como grupo, tuvieron igual tratamiento e igual resultado que los hombres. Los diabéticos constituyen un grupo de muy alta mortalidad que no parece depender de la estrategia de tratamiento, sino más bien de la patología de fondo y sus complicaciones. Los pacientes mayores tienen una alta mortalidad, pero aún queda por resolver si se puede abatir, al menos en parte, modificando las pautas terapéuticas, utilizando en mayor porcentaje la trombolisis y la medicación coadyuvante. La tercera parte de los pacientes que fallecieron lo hicieron en las primeras 24 horas. COMECA esta basada en Canelones, pero recibe pacientes de Santa Lucía, Cerrillos, Tala, Santa Rosa, San Bautista, San Ramón, Juanicó y otras localidades cuando se trata de pacientes de otras Cooperativas o de Salud Pública, lo que indica que se deben estudiar conductas para abatir el tiempo entre el comienzo de los síntomas y el inicio de la trombolisis. Considerando que las normas de la AHA/ACC plantean como desideratum una hora para dicho período, se deberá cosiderar, al igual que se está haciendo en EE.UU. y Europa, la administración extrahospitalaria de trombolíticos. Por otra parte, la proximidad a Montevideo y a centros terciarios, debe hacer cosiderar la utilización de angioplastia primaria, al menos en aquellos pacientes con contraindicaciones para la trombolisis. Pero ello, también exige una mayor educación de la población general, para lograr consultas más precoces, y una disminución del tiempo entre el comienzo del dolor y la llegada a un centro donde se puedan tomar decisiones y se puedan instrumentar

Infarto agudo de miocardio. Experiencia de 7 años en el departamento de Canelones / Acute myocardial infarction: seven years experience in the department of Canelones

Se realizo un estudio retrospectivo que cubrio los egresos por Infarto Agudo de Miocardio de las tres Unidades de Medicina Intensiva del departamento de Canelones entre 1987 y 1993. El 32.4 por ciento de los pacientes recibieron Estreptokinasa (STK), con una mortalidad del 13.2 por ciento, mientras que la mortalidad en los pacientes que no recibieron fibrinoliticos fue del 25 por ciento, significativamente mayor. Se determino que la poblacion atendida en Canelones es mas anciana que las tratadas en EE.UU. y Europa, factor que influye negativamente en la mortalidad global de la serie. El 22 por ciento de los pacientes ingresaron en clase de killip y kimball 3 o 4, pautando que en Canelones los pacientes ingresan en una situacion hemodinamica mas comprometida que lo publicado internacionalmente, y junto a una mortalidad excesivamente alta para los pacientes con edema agudo de pulmon muestran un area donde se debe trabajar para mejorar los resultados actuales

Infarto agudo de miocardio: experiencia de cinco años en el Departamento de Canelones / Acute myocardial infarction: five years experience in Canelones

Se estudiaron 257 pacientes ingresados por infarto agudo de miocardio en las tres Unidades de Cuidados Intensivos del Departamento de Canelones en el período 1987-91. Edad de 65 ñ 11 años y predominio del sexo masculino (68 por ciento). La mortalidad global fue de 21 por ciento. El 59 por ciento de los pacientes ingresó en clase I de Killip con mortalidad de 3,9 por ciento; 18 por ciento ingresaron en clase II, con mortalidad de 29,6 por ciento; 11 y 12 por ciento de los pacientes ingresaron en clase III y IV, con mortalidades de 60,7 por ciento y 66,7 por ciento. En 57 pacientes (22,5 por ciento) se realizó tratamiento trombolítico, con una mortalidad para este subgrupo de 5,3 por ciento, significativamente menor que para el subgrupo de pacientes que no recibieron dicho tratamiento (25,5 por ciento). La administración concomitante de ácido acetilsalicílico o de betabloqueadores, o de ambos, contribuyó en forma importante a la disminución de la mortalidad de los pacientes que recibieron el tratamiento trombolítico