Obesity and the obesity paradox in patients with severe COVID-19 / Obesidad y paradoja de la obesidad en pacientes con COVID-19 severo: Resultados de dos cohortes prospectivas

Objective: To test the presence of the obesity paradox in two cohorts of patients hospitalized for COVID-19. Design: Two multicenter prospective cohorts. Setting: Three fourth level institutions. Patients: Adults hospitalized in the general ward for confirmed COVID-19 in the three institutions and those admitted to one of the 9 critical care units of one of the institutions. Interventions: None. Main variables of interest: Categorized weight and its relationship with admission to the ICU in hospitalized patients and death in the ICU. Result: Of 402 hospitalized patients, 30.1% were obese. Of these, 36.1% were admitted to the ICU vs. 27.1% of non-obese patients. Of the 302 ICU patients, 46.4% were obese. Of these, mortality was 45.0% vs. 52.5% for non-obese. The requirement to transfer hospitalized patients to the ICU admission get a HR of 1.47 (95%CI 0.87–2.51, p = 0.154) in the multivariate analysis. In intensive care patients, an HR of 0.99 (95%CI: 0.92–1.07, p = 0.806) was obtained to the association of obesity with mortality. Conclusions: The present study does not demonstrate an association between obesity and risk of inpatient transfer to intensive care or death of intensive care patients due to COVID-19 therefore, the presence of an obesity paradox is not confirmed. (AU)

Objetivo: Comprobar la presencia la paradoja de la obesidad en dos cohortes de pacientes hospitalizados por COVID-19. Diseño: Dos cohortes prospectivas multicéntricas. Ámbito: Tres instituciones de cuarto nivel. Pacientes: Adultos hospitalizados en pabellón general por COVID-19 confirmado en las tres instituciones y aquellos internados en alguna de las 9 unidades de cuidado crítico de una de las instituciones. Intervenciones: Ninguna. Variables de interés principales: El peso categorizado y su relación con el ingreso a UCI en hospitalizados y de muerte en UCI. Resultado: Entre 402 hospitalizados 30.1% fueron obesos, de los que 36.1% ingresaron a UCI vs. 27.1% en los no obesos. De los 302 pacientes en UCI, el 46.4% fueron obesos, entre ellos la mortalidad fue de 45.0% vs. 52.5% en los no obesos. En hospitalizados el análisis multivariado obtuvo HR de 1.47 (IC95% 0.87–2.51, p = 0.154) para traslado a UCI. En UCI se obtuvo un OR de 0.99 (IC95%: 0.92–1.07, p = 0.806) para la muerte. Conclusiones: El presente estudio no demuestran una asociación entre la obesidad y el riesgo de traslados a cuidados intensivos en pacientes hospitalizados ni con la muerte en pacientes en cuidados intensivos por COVID-19 por lo que no se confirma la presencia de una paradoja de la obesidad. (AU)

Variables influencing the prediction of fluid responsiveness: a systematic review and meta-analysis.

INTRODUCTION: Prediction of fluid responsiveness in acutely ill patients might be influenced by a number of clinical and technical factors. We aim to identify variables potentially modifying the operative performance of fluid responsiveness predictors commonly used in clinical practice. METHODS: A sensitive strategy was conducted in the Medline and Embase databases to search for prospective studies assessing the operative performance of pulse pressure variation, stroke volume variation, passive leg raising (PLR), end-expiratory occlusion test (EEOT), mini-fluid challenge, and tidal volume challenge to predict fluid responsiveness in critically ill and acutely ill surgical patients published between January 1999 and February 2023. Adjusted diagnostic odds ratios (DORs) were calculated by subgroup analyses (inverse variance method) and meta-regression (test of moderators). Variables potentially modifying the operative performance of such predictor tests were classified as technical and clinical. RESULTS: A total of 149 studies were included in the analysis. The volume used during fluid loading, the method used to assess variations in macrovascular flow (cardiac output, stroke volume, aortic blood flow, volume‒time integral, etc.) in response to PLR/EEOT, and the apneic time selected during the EEOT were identified as technical variables modifying the operative performance of such fluid responsiveness predictor tests (p < 0.05 for all adjusted vs. unadjusted DORs). In addition, the operative performance of fluid responsiveness predictors was also influenced by clinical variables such as the positive end-expiratory pressure (in the case of EEOT) and the dose of norepinephrine used during the fluid responsiveness assessment for PLR and EEOT (for all adjusted vs. unadjusted DORs). CONCLUSION: Prediction of fluid responsiveness in critically and acutely ill patients is strongly influenced by a number of technical and clinical aspects. Such factors should be considered for individual intervention decisions.

Obesity and the obesity paradox in patients with severe COVID-19.

OBJECTIVE: To test the presence of the obesity paradox in two cohorts of patients hospitalized for COVID-19. DESIGN: Two multicenter prospective cohorts. SETTING: Three fourth level institutions. PATIENTS: Adults hospitalized in the general ward for confirmed COVID-19 in the three institutions and those admitted to one of the 9 critical care units of one of the institutions. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: Categorized weight and its relationship with admission to the ICU in hospitalized patients and death in the ICU. RESULT: Of 402 hospitalized patients, 30.1% were obese. Of these, 36.1% were admitted to the ICU vs. 27.1% of non-obese patients. Of the 302 ICU patients, 46.4% were obese. Of these, mortality was 45.0% vs. 52.5% for non-obese. The requirement to transfer hospitalized patients to the ICU admission get a HR of 1.47 (95%CI 0.87-2.51, p = 0.154) in the multivariate analysis. In intensive care patients, an HR of 0.99 (95%CI: 0.92-1.07, p = 0.806) was obtained to the association of obesity with mortality. CONCLUSIONS: The present study does not demonstrate an association between obesity and risk of inpatient transfer to intensive care or death of intensive care patients due to COVID-19 therefore, the presence of an obesity paradox is not confirmed.

[Adherence to the Clinical Practice Guidelines for the hospital management of patients with decompensated heart failure in a Coronary Care Unit in Colombia]. / Adherencia a la guía de práctica clínica para el manejo hospitalario de pacientes con insuficiencia cardíaca descompensada en una unidad de cuidados coronarios de Colombia.

Objective: To assess adherence to the recommendations for the diagnosis and management of hospitalized patients with Decompensated Heart Failure issued by the European Society of Cardiology in 2021 at a Coronary Care Unit at a fourth-level hospital in the city of Bogotá. Materials and Methods: A descriptive cross-sectional study was conducted, including hospitalized patients in the Coronary Care Unit at Hospital San José in Bogotá, with a primary diagnosis of Decompensated Heart Failure, from September 2021 to January 2023. Patient data were collected from medical records. Adherence to the Decompensated Heart Failure guidelines was described in the study. Results: High adherence was observed for laboratory tests and medication prescriptions recommended by the 2021 European Society of Cardiology guidelines. However, there was low adherence to the request for thyroid function tests, troponin, and iron studies. The cause of heart failure and decompensation was adequately recorded. The most common cause of decompensation was acute coronary syndrome. Regarding the hemodynamic profile on admission, the majority presented as Stevenson B. Pharmacological adherence to Class I recommendations showed high compliance in prescribing beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and Angiotensin Receptor-Neprilysin Inhibitors. However, lower adherence was observed for Sodium-glucose co-transporter two inhibitors and Mineralocorticoid receptor antagonists. Conclusions: Variable adherence rates were recorded, emphasizing satisfactory compliance with class I recommendations for certain medications and laboratory tests. It is necessary to improve adherence in the request for paraclinicals, especially in thyroid function tests and ferrokinetic profiles.

Profilaxis para sangrado gastrointestinal en pacientes del servicio de medicina interna de un hospital universitario / Gastrointestinal bleeding prophylaxis in internal medicine patients of a univeristy hospital

Introducción: Los medicamentos antiulcerosos son utilizados frecuentemente en pacientes hospitalizados, sin embargo, a menudo este uso no está indicado. Objetivo: Describir la frecuencia de prescripción e indicación de medicamentos para prevenir el sangrado gastrointestinal en pacientes hospitalizados. Materiales y métodos: Estudio de corte trasversal, descriptivo, prospectivo del servicio de Medicina Interna de la Sociedad de Cirugía de Bogotá- Hospital de San José de Bogotá, Colombia. Se excluyeron pacientes con diagnóstico de sangrado gastrointestinal o antecedente de alergia a los medicamentos antiulcerosos. Se recolectaron datos demográficos, así como fármacos prescritos. Se determinó si la indicación del fármaco era adecuada y se identificó el tipo de error de prescripción. Resultados: Se incluyeron 179 pacientes, 102 (57%) mujeres. Promedio de edad de 61,3 años (±20,2). El principal diagnóstico de ingreso fue enfermedad infecciosa 76 (42,4%). Del total de pacientes, 165 (92,17%) recibieron medicamento para prevención del sangrado gastrointestinal. La indicación fue adecuada en 75 pacientes (41,89%). El error más frecuente fue el uso en pacientes de bajo riesgo de sangrado, 101 (97,1%). Conclusión: Un alto porcentaje de los pacientes recibió medicación para la prevención del sangrado gastrointestinal. En aproximadamente la mitad de estos no estaba indicada.

Introduction: Anti-ulcer medications are frequently used in hospitalized patients, yet their use is not usually indicated. Objective: To describe the frequency of prescription and indication of medications to prevent gastrointestinal bleeding in hospitalized patients. Materials and methods: A cross-sectional, descriptive, prospective study was carried out in the Internal Medicine service of the Surgery Society of Bogota-San Jose Hospital of Bogota (Colombia). Excluded patients were those with either a gastrointestinal bleeding diagnosis or a history of allergy to anti-ulcer medications. Demographic data and information regarding prescribed medications were collected. It was determined whether the medicine indication was adequate and the type of prescription error was identified. Results: 179 patients were included in the study, 57% (102) of which were women. The average age was 61.3 (±20.2) years old. Infectious disease was the main admission diagnosis (76; 42.4%). A 92.17% (165) of the total number of patients received medications to prevent gastrointestinal bleeding. This indication was adequate for 75 (41.89%) patients. The most frequent error was their use in bleeding low-risk patients (101; 97.1%). Conclusion: A high percentage of patients received medication to prevent gastrointestinal bleeding. However, in about half of these patients it was not indicated.

Physiological variables of the "metabolic component" of acid-base balance and mortality in intensive care patients / Variables fisiológicas del "componente metabólico" del estado ácido base y mortalidad en pacientes de cuidados intensivos

Abstract Introduction: Metabolic acidosis is a frequent pathophysiological condition in critically ill patients. It can be assessed using different physiological variables, but their prognostic value has not yet been well established. Objective: To evaluate the association between the variables that allow assessing the metabolic component of acid-base balance (ABB) and 28-day mortality in patients admitted to an intensive care unit (ICU) in Bogotá, D.C., Colombia. Materials and methods: Prospective cohort study conducted in 122 patients admitted to an ICU between January and June 2013 and with a stay >24 hours. On admission to the ICU, blood samples were taken, and an arterial blood gas test was performed in order to calculate the following variables: anion gap (AG), corrected anion gap (AGc), standard base excess (BEst), metabolic H+, base excess-unmeasurable anions (BEua), arterial pH, arterial lactate, standard HCO3-st, and strong ion difference (SID). APACHE II and SOFA scores were also calculated. A bivariate analysis was performed in which ORs and their respective 95%CI were calculated, and then a multivariate analysis was conducted using a logistic regression model to identify the variables associated with 28-day mortality; a significance level of p<0.05 was considered. Results: Out of the 122 patients, 33 (27.05%) died at 28 days and 51 (48.80%) were women. Participants' mean age was 46.5 years (±15.7). The following variables were significantly associated with 28-day mortality in the bivariate analysis: SID (OR=1.150; p=0.008), BEua (OR=0.897; p=0.023), AG (OR=1.231; p=0.002), AGc (OR=1.232; p=0.003), blood pH (OR=0.001; p=0.023), APACHE II (OR=1.180; p=0.001), HCO3-st (OR=0.841; p=0.015). In the multivariate analysis, only the APACHE II score variable was significantly associated with 28-day mortality (OR=1.188; p=0.008). Conclusion: The physiological variables that allow assessing the metabolic component of ABB, both from the Henderson model and the Stewart model, were not significantly associated with 28-day mortality.

Resumen Introducción. La acidosis metabólica es una condición fisiopatológica frecuente en pacientes críticamente enfermos. Esta alteración es evaluada mediante diferentes variables fisiológicas; sin embargo, su valor pronóstico aún no está bien definido. Objetivo. Evaluar la asociación entre, por una parte, las variables del componente metabólico que permiten valorar el estado ácido base (EAB) y, por la otra, la mortalidad a 28 días en pacientes hospitalizados en una unidad de cuidados intensivos (UCI) en Bogotá D.C., Colombia. Materiales y métodos. Estudio de cohorte prospectivo realizado en 122 pacientes hospitalizados en una UCI entre enero y junio de 2013 y con una estancia mayor a 24 horas. Se tomaron muestras sanguíneas y gases arteriales de ingreso a UCI para el cálculo de las siguientes variables: anion gap (AG), anion gap corregido (AGc), base exceso estándar (BEst), H+ metabólicos, base exceso-aniones no medibles (BEua), pH arterial, lactato arterial, HCO3-st y brecha de iones fuertes (BIF). También se calcularon el puntaje APACHE II y el puntaje SOFA. Se realizó un análisis bivariado en el que se calcularon OR y sus respectivos IC95%, y luego uno multivariado, mediante un modelo de regresión logística, para identificar las variables asociadas con la mortalidad a 28 días; se consideró un nivel de significancia de p<0.05 Resultados. De los 122 pacientes, 33 (27.05%) fallecieron a 28 días y 51 (48.80%) eran mujeres. La edad promedio fue 46.5 años (±15.7). En el análisis bivariado, las siguientes variables se asociaron significativamente con la mortalidad a 28 días: BIF (OR=1.150; p=0.008), BEua (OR=0.897; p=0.023), AG (OR=1.231; p=0.002), AGc (OR=1.232; p=0.003), pH arterial (OR=0.001; p=0.023), APACHE II (OR=1.180;p=0.001), HCO3-st (OR=0.841;p=0.015). En el análisis multivariado, solo el puntaje APACHE II se asoció significativamente con la mortalidad a 28 días (OR=1.188; p=0.008). Conclusión. Las variables fisiológicas que permiten evaluar el componente metabólico del EAB, tanto las del modelo de Henderson, como las del modelo de Stewart, no se asociaron significativamente con la mortalidad a 28 días.

Changes of operative performance of pulse pressure variation as a predictor of fluid responsiveness in endotoxin shock.

Several limitations regarding pulse pressure variation (PPV) use have been reported. Our aim was to describe changes in the PPV operative performance as a predictor of fluid responsiveness during the development of a swine endotoxin shock model and to assess hemodynamic variables associated with PPV changes. A swine porcine endotoxin shock model was established (Escherichia Coli 055:B5 endotoxin) in 7 pigs, and 3 pigs were included in the control group. The endotoxin was infused until the mean arterial pressure (MAP) dropped below 50 mmHg (TH0); then, the model animal was reanimated with fluids and vasopressors. We performed fluid challenges every hour for 6 h. ROC curve analysis and a linear mixed model were performed. The area under the curve of PPV decreased from 0.95 (0.81-1.00) to 0.60 (0.17-1.00) at TH0. Its cutoff increased from 10.5 to 22.00% at TH0. PPV showed an inverse relationship with stroke volume, mean systemic filling pressure, MAP, and systemic vascular resistance (SVR) (p < 0.001, AIC = 111.85). The PPV operative performance as a predictor of fluid responsiveness decreased with the progression of shock. This could lead to an inverse association between PPV and the following variables: MAP and SVR.

Predictors of fluid responsiveness in critically ill patients mechanically ventilated at low tidal volumes: systematic review and meta-analysis.

INTRODUCTION: Dynamic predictors of fluid responsiveness have shown good performance in mechanically ventilated patients at tidal volumes (Vt) > 8 mL kg-1. Nevertheless, most critically ill conditions demand lower Vt. We sought to evaluate the operative performance of several predictors of fluid responsiveness at Vt ≤ 8 mL kg-1 by using meta-regression and subgroup analyses. METHODS: A sensitive search was conducted in the Embase and MEDLINE databases. We searched for studies prospectively assessing the operative performance of pulse pressure variation (PPV), stroke volume variation (SVV), end-expiratory occlusion test (EEOT), passive leg raising (PLR), inferior vena cava respiratory variability (Δ-IVC), mini-fluid challenge (m-FC), and tidal volume challenge (VtC), to predict fluid responsiveness in adult patients mechanically ventilated at Vt ≤ 8 ml kg-1, without respiratory effort and arrhythmias, published between 1999 and 2020. Operative performance was assessed using hierarchical and bivariate analyses, while subgroup analysis was used to evaluate variations in their operative performance and sources of heterogeneity. A sensitivity analysis based on the methodological quality of the studies included (QUADAS-2) was also performed. RESULTS: A total of 33 studies involving 1,352 patients were included for analysis. Areas under the curve (AUC) values for predictors of fluid responsiveness were: for PPV = 0.82, Δ-IVC = 0.86, SVV = 0.90, m-FC = 0.84, PLR = 0.84, EEOT = 0.92, and VtC = 0.92. According to subgroup analyses, variations in methods to measure cardiac output and in turn, to classify patients as responders or non-responders significantly influence the performance of PPV and SVV (p < 0.05). Operative performance of PPV was also significantly affected by the compliance of the respiratory system (p = 0.05), while type of patient (p < 0.01) and thresholds used to determine responsiveness significantly affected the predictability of SVV (p = 0.05). Similarly, volume of fluids infused to determine variation in cardiac output, significantly affected the performance of SVV (p = 0.01) and PLR (p < 0.01). Sensitivity analysis showed no variations in operative performance of PPV (p = 0.39), SVV (p = 0.23) and EEOT (p = 0.15). CONCLUSION: Most predictors of fluid responsiveness reliably predict the response of cardiac output to volume expansion in adult patients mechanically ventilated at tidal volumes ≤ 8 ml kg-1. Nevertheless, technical and clinical variables might clearly influence on their operative performance.

Use of Pulse Pressure Variation as Predictor of Fluid Responsiveness in Patients Ventilated With Low Tidal Volume: A Systematic Review and Meta-Analysis.

INTRODUCTION: Pulse pressure variation (PPV) has been shown to be useful to predict fluid responsiveness in patients ventilated at tidal volume (Vt) >8 mL kg-1. Nevertheless, most conditions in critical care force to use lower Vt. Thus, we sought to evaluate the operative performance of PPV when a Vt ⩽8 mL kg-1 is used during mechanical ventilation support. METHODS: We searched PubMed and Embase databases for articles evaluating the operative performance of PPV as a predictor of fluid responsiveness in critical care and perioperative adult patients ventilated with tidal volume ⩽8 mL kg-1 without respiratory effort and arrhythmias, between January 1990 and January 2019. We included cohort and cross-sectional studies. Two authors performed an Independently selection using predefined terms of search. The fitted data of sensitivity, specificity, and area under the curve (AUC) were assessed by bivariate and hierarchical analyses. RESULTS: We retrieved 19 trials with a total of 777 patients and a total of 935 fluid challenges. The fitted sensitivity of PPV to predict fluid responsiveness during mechanical ventilation at Vt ⩽8 mL kg-1 was 0.65 (95% confidence interval [CI]: 0.57-0.73), the specificity was 0.79 (95% CI: 0.73-0.84), and the AUC was 0.75. The diagnostic odds ratio was 5.5 (95% CI: 3.08-10.01, P < .001) by the random-effects model. CONCLUSIONS: Pulse pressure variation shows a fair operative performance as a predictor of fluid responsiveness in critical care and perioperative patients ventilated with a tidal volume ⩽8 mL kg-1 without respiratory effort and arrhythmias.

Comparative analysis of acid-base balance in patients with severe sepsis and septic shock: traditional approach vs. physicochemical approach / Análisis comparativo del equilibrio ácido-base en pacientes con sepsis severa y choque séptico: enfoque tradicional versus enfoque físico-químico

Abstract Introduction: The evaluation of metabolism and the diagnostic classification of acid-base disorders has generated great controversy. Acid-base balance (ABB) is approached by means of the physicochemical and Henderson's models. Objective: To compare two diagnostic approaches to ABB in patients with severe sepsis. Materials and methods: Prospective, descriptive study conducted in patients with severe sepsis. ABB was analyzed within the first 24 hours. The diagnosis was compared according to each model and the causes of the disorders were compared according to the physicochemical model. Results: 38 patients were included in the study, of which 21 (55%) were women; the mean age was 49 years, the median APACHE II, 13.28, and the mortality at 28 days, 24.3%. The traditional approach identified 8 patients with normal ABB, 20 with metabolic acidosis, and 10 with other disorders. Based on the physicochemical model, all subjects had acidosis and metabolic alkalosis. Increased strong ion difference (SID) was the most frequently observed disorder. Conclusion: The physicochemical model was useful to diagnose more patients with acid-base disorders. According to these results, all cases presented with acidosis and metabolic alkalosis; the most frequent proposed mechanism of acidosis was elevated SID. The nature of these disorders and their clinical relevance is yet to be established.

Resumen Introducción. Existe gran controversia en la evaluación del componente metabólico y en la clasificación diagnóstica de las alteraciones del equilibrio ácido-base (EAB), el cual se aborda mediante los modelos físico-químico y de Henderson. Objetivo. Comparar dos enfoques diagnósticos del EAB en pacientes con sepsis severa. Materiales y métodos. Estudio descriptivo prospectivo realizado en pacientes con sepsis severa. Se analizó el EAB en las primeras 24 horas; el diagnóstico se comparó según cada modelo y las causas de alteraciones, según el modelo físico-químico. Resultados. Se analizaron 38 pacientes (55% mujeres) con edad promedio de 49 años, mediana APACHE II de 13 y mortalidad a 28 días del 24.3%. El enfoque tradicional identificó 8 pacientes con EAB normal, 20 con acidosis metabólica y 10 con otros trastornos. En el modelo físico-químico, los 38 pacientes tuvieron alteraciones denominadas acidosis y alcalosis metabólica; el aumento de la brecha de iones fuertes (SIG, por su sigla en inglés) fue la más frecuente. Conclusión. El modelo físico-químico diagnosticó más pacientes con alteraciones ácido-base. Según este, todos tuvieron acidosis y alcalosis metabólica y el mecanismo propuesto más frecuente de acidosis fue el SIG elevado. La naturaleza de estas alteraciones y su significado clínico está por definirse.

Effectiveness of a case management model for the comprehensive provision of health services to multi-pathological people.

AIM: To determine the effectiveness of a case management model for approaching multi-pathological people in a health promoting entity of the contributory healthcare scheme in Bogotá, Colombia between 2018 - . DESIGN: Mixed methods research. METHOD: The study contemplates two components: a quantitative component using a quasi-experimental analytical design before and after longitudinal intervention to determine the effectiveness of the case management model and a qualitative descriptive design to understand the experience of the participants about the model. The Administrative Department of Science, Technology and Innovation of Colombia (Colciencias) funded this project by means of call 777-November 2017, under the financing agreement No. 848-December 2017. DISCUSSION: Addressing problems deriving from the structure of the Colombian healthcare system is crucial for implementing case management models. Furthermore, the effectiveness of such models may be affected by power relations and market failures, but the proved potential of a model may represent a generalized benefit for the Colombian health system. IMPACT: In Colombia, considering complications and management of chronic non-communicable diseases as isolated cases is considered as the highest cost events in healthcare provision, since an average of 12.8 million pesos is invested in each patient. This has led to rethink the management in these patients by means of a comprehensive model that guarantees the effectiveness of healthcare delivery, in the framework of a healthcare system heavily affected by payment capacity, where the market has a strong predominance, such as the case of Colombia. TRIAL REGISTRATION NUMBER: RPCEC00000293.

Asociación entre hiponatremia, mortalidad y estancia hospitalaria en pacientes con falla cardíaca descompensada / Association between hyponatremia, mortality and hospitalization in patients with acute decompensated Heart Failure / Associação entre hiponatremia, mortalidade e internação hospitalar em pacientes com insuficiência cardíaca descompensada

Introducción. La hiponatremia es la alteración electrolítica más frecuente en pacientes con falla cardíaca crónica, que afecta hasta el 28% de pacientes en el ingreso hospilatario. Se ha demostrado que es un predictor independiente de mortalidad, estancia prolongada y rehospitalización. El objetivo es describir la frecuencia de hiponatremia en pacientes con falla cardíaca descompensada y su relación con la estancia hospitalaria y mortalidad. Metodología. Cohorte prospectiva en pacientes hospitalizados por el servicio de Medicina Interna en un hospital de cuarto nivel de Bogotá, Colombia, con diagnóstico de falla cardíaca descompensada entre abril de 2011 y marzo de 2012. Se midió el sodio al ingreso, a las 72 horas y al día séptimo de hospitalización. Se evaluó la relación de la hiponatremia al ingreso con la estancia hospitalaria y la mortalidad intrahospitalaria a 30 días. Resultados. Se incluyeron 162 pacientes, con promedio de edad de 72 años, 52.5% hombres. Cuarenta y uno (25.3%) presentaron hiponatremia al ingreso. Entre los pacientes que presentaron sodio normal al ingreso, 6 presentaron hiponatremia a las 72 horas y 2 a los 7 días. La mortalidad intrahospitalaria en la población total fue 9.2%, en el grupo de hiponatremia 12.2%, y 8.2% en los que no la tuvieron (p= 0.45). El promedio de estancia hospitalaria fue superior en los pacientes con hiponatremia, 6.6 vs. 8.4 días (p= 0.12). Discusión. La incidencia de hiponatremia al ingreso en este grupo de pacientes fue semejante a la reportada en la literatura. Conclusiones. Existe una tendencia hacia una mayor mortalidad y estancia hospitalaria en pacientes con hiponatremia, aun cuando no fue estadísticamente significativa. Cómo citar. Diaztagle-Fernández JJ, Chaves-Saltiago WG, Sprockel-Díaz JJ, Acevedo-Velasco AD, Rodríguez-Benítez FH, Benavides-Solarte MF, et al. Asociación entre hiponatremia, mortalidad y estancia hospitalaria en pacientes con falla cardíaca descompensada. MedUNAB. 2019;22(3), 294-303. doi: 10.29375/01237047.3497

Introduction. Hyponatremia is the most common electrolyte disorder in patients with chronic heart failure affecting up to 28% of patients at admission. It has been shown to be an independent predictor of mortality, extended length of hospital stay and rehospitalization. The objective is to evaluate the presence of hyponatremia in patients with decompensated heart failure and describe its relationship with length of hospital stay and mortality. Methodology. A prospective cohort study in patients hospitalized at internal medicine service at a high level of complexity hospital in Bogotá, Colombia diagnosed with decompensated heart failure between April 2011 and March 2012. Sodium was measured on admission, 72 hours and at the seventh day of hospitalization. We evaluated the association between hyponatremia at hospital admission, mortality at 30 days and length of hospital stay. Results. 162 patients were included with an average age of 72 years, 52.5% male. Forty-one (25.3%) had hyponatremia at admission. Among the patients with normal sodium at admission, 6 had hyponatremia at 72 hours and 2 at the seventh day. Inhospital mortality in the total population was 9.2%, in the hyponatremia group 12.2%, and 8.2% in those who did not have it (p = 0.45). The average length of hospital stay was higher in patients with hyponatremia, 6.6 vs 8.4 days (p = 0.12). Discussion. The incidence of hyponatremia at admission in this group of patients was similar to that reported in the literature. Conclusions. The results showed a trend towards higher mortality and hospital stay in patients with hyponatremia, even though it was not statistically significant. Cómo citar. Diaztagle-Fernández JJ, Chaves-Saltiago WG, Sprockel-Díaz JJ, Acevedo-Velasco AD, Rodríguez-Benítez FH, Benavides-Solarte MF, et al. Asociación entre hiponatremia, mortalidad y estancia hospitalaria en pacientes con falla cardíaca descompensada. MedUNAB. 2019;22(3), 294-303. doi: 10.29375/01237047.3497

Introdução. A hiponatremia é o desequilíbrio hidroeletrolítico mais frequente em pacientes com insuficiência cardíaca crônica, que afeta até 28% dos pacientes internados. Demonstrou ser um preditor independente de mortalidade, permanencia prolongada e re-internação. O objetivo é descrever a frequência de hiponatremia em pacientes com insuficiência cardíaca descompensada e sua relação com internação hospitalar e mortalidade. Metodologia. Coorte prospectiva em pacientes internados pelo serviço de Medicina Interna em um hospital de quarto nível em Bogotá, Colômbia, com diagnóstico de insuficiência cardíaca descompensada, entre abril de 2011 e março de 2012. Foi medido o sódio na admissão, às 72 horas e no sétimo dia de internação. Foi avaliada a relação de hiponatremia na admissão com internação e a mortalidade hospitalar aos 30 dias. Resultados. Foram incluídos 162 pacientes, com idade média de 72 anos, 52,5% homens. Quarenta e um (25,3%) apresentaram hiponatremia na admissão. Entre os pacientes que apresentaram sódio normal na admissão, seis apresentaram hiponatremia às 72 horas, e dois aos sete dias. A mortalidade hospitalar na população total foi de 9,2%, no grupo de hiponatremia 12,2% e 8,2% naqueles que não apresentaram (p = 0,45). O tempo médio de internação foi maior nos pacientes com hiponatremia, 6,6 vs. 8,4 dias (p = 0,12). Discussão. A incidência de hiponatremia na admissão nesse grupo de pacientes foi semelhante à relatada na literatura. Conclusões. Existe uma tendência de maior mortalidade e permanência hospitalar em pacientes com hiponatremia, mesmo que não tenha sido estatisticamente significante. Cómo citar. Diaztagle-Fernández JJ, Chaves-Saltiago WG, Sprockel-Díaz JJ, Acevedo-Velasco AD, Rodríguez-Benítez FH, Benavides-Solarte MF, et al. Asociación entre hiponatremia, mortalidad y estancia hospitalaria en pacientes con falla cardíaca descompensada. MedUNAB. 2019;22(3), 294-303. doi: 10.29375/01237047.3497

Research on heart failure in Colombia 1980-2015: a systematic review / La investigación en falla cardíaca en Colombia 1980-2015: una revisión sistemática

Abstract Introduction: Heart failure is one of the most prevalent diseases worldwide. In Colombia, the state of research on the subject is unknown. Objective: To describe the original publications on heart failure in Colombia. Materials and methods: Systematic review. Digital search in Embase, PubMed, LILACS and Scielo, using the MeSH terms: "heart failure", "Colombian", "Colombia", "Latin America", "developing countries". Manual search of 58 journals identified in Publindex. Original research that evaluated adult Colombians with heart failure and published between 1980 and 2015 were included. Results: 2 684 articles were identified, of which 35 met the inclusion criteria. 30 (85.7%) were published since 2009, 30 (85.7%) were conducted in Bogotá and Medellín, 11 (31.4%) had n>200, 19 (54.2%) were descriptive and 5 (14.2%) quasi-experimental. Moreover, 9 (25.7%) described general populations, 9 (25.7%) addressed the issue of self-care, 3 (8.8%) cardiac rehabilitation, 3 (8.8%) perception of the disease and 3 (8.8%) prognostic factors. Conclusions: The amount of published original research on heart failure is low, and most of them were carried out recently. Descriptive design was the most frequent, while the most frequently addressed topics were self-care and population descriptions.

Resumen Introducción. La falla cardíaca es una de las enfermedades con mayor prevalencia a nivel mundial. En Colombia no se conoce con certeza el estado de la investigación en torno al tema. Objetivo. Describir las publicaciones originales en falla cardíaca en Colombia. Materiales y métodos. Revisión sistemática. Búsqueda electrónica en Embase, PubMed, LILACS Y SciELO, con términos MeSH: "heart failure", "colombian", "Colombia", "Latin America", "developing countries". Búsqueda manual en 58 revistas identificadas en Publindex. Se incluyeron investigaciones originales, publicadas entre 1980 y 2015, que evaluaron población adulta colombiana con falla cardíaca. Resultados. Se identificaron 2 684 artículos: 35 cumplieron criterios de inclusión; 30 (85.7%) fueron publicados a partir del 2009; 30 (85.7%) se realizaron en Bogotá y Medellín; 11 (31.4%) tuvieron n>200; 19 (54.2%) fueron descriptivos y 5 (14.2%) cuasiexperimentales; 9 (25.7%) describieron poblaciones generales; 9 (25.7%) abordaron el tema del autocuidado, 3 (8.8%), la rehabilitación cardíaca, 3 (8.8%), la percepción de enfermedad y 3 (8.8%), los factores pronósticos. Conclusión. El número de investigaciones originales publicadas sobre falla cardíaca es escaso; la mayoría se realizó en los últimos años. El diseño descriptivo fue el más común. Los temas abordados con mayor frecuencia fueron el autocuidado y las descripciones poblacionales.

Medidas de desempeño de la calidad de atención en pacientes con infarto agudo de miocardio con elevación ST en el hospital de San José de Bogotá, 2014 / Performance measures in quality of care of patients with acute myocardial infarction with ST elevation in hospital of San José of Bogotá

RESUMEN Introducción: el infarto agudo de miocardio con elevación del ST, es una entidad con alto impacto en mortalidad en la población mundial. Es indispensable un oportuno diagnóstico e inicio de terapia de reperfusión de forma eficaz. Objetivo: reevaluar las medidas de desempeño en el manejo del infarto de miocardio con elevación del segmento ST. Materiales y método: estudio descriptivo prospectivo de serie de casos recolectados durante seis meses en el 2014, se revisaron los pacientes que tenían diagnóstico de infarto agudo de miocardio con elevación del ST y se consignaron sus características mas las diferentes medidas de desempeño de la calidad de atención en el Hospital San José. Resultados: se incluyeron 26 pacientes, de los cuales 19 llegaron a ventana siendo estos trombolizados. La mediana del tiempo puerta electrocardiograma fue de 16 minutos, y del tiempo puerta aguja 57 minutos. La adherencia fue del 100% para los betabloqueadores, acido acetilsalicílico y los inhibidores de la enzima convertidora de angiotensina, mientras que la consejería de toma de tensión arterial ambulatoria y rehabilitación cardiaca fue del 86,9% y 82,6% respectivamente. Por otro lado, solo el 8,6% de los pacientes cumplieron con la toma de niveles de lípidos y 62,5% tuvieron consejería para abandono de tabaco. La mortalidad hospitalaria fue 8,7%. Conclusiones: se encontró una alta tasa de cumplimiento de las medidas de desempeño en el manejo del infarto agudo de miocardio con elevación del ST, excepto en la medición de los niveles de lípidos. Se evidencio un moderado retroceso en los tiempos de intervención en el diagnóstico y en implementación de una terapia farmacológica de reperfusión (tiempo puerta-electrocardiograma y tiempo puerta aguja) manteniéndose las mismas tasas de mortalidad. MÉD.UIS. 2016;29(3):27-32.

ABSTRACT Introduction: acute myocardial infarction with ST elevation is an entity that has a high impact on mortality worldwide. Early diagnosis and starting an effective reperfusion therapy are indispensable. Objective: to reevaluated the performance measures for the management of myocardial infarction. Methods: 6-month from 2014 descriptive, prospective case series study of patients diagnosed with acute myocardial infarction with ST elevation were reviewed and their characteristics and the different performance measures of the quality of care were recorded. Results: 26 patients were included, 19 of which received thrombolytic therapy, all of those in window. The median door-toEKG time was 16 minutes, and door-needle time was 57 minutes. Discharge orders had 100% adherence to beta-blockers, ASA, and ACE inhibitors; 86.9% and 82.6% to ambulatory blood pressure counseling and cardiac rehabilitation respectively; in the other side, only 8.6% had lipid levels measurements; and 62.5% had a tobacco counseling. Hospital mortality was 8.7%. Conclusions: a high rate of fulfillment of the measures to manage acute myocardial infarction with ST elevation was found, except for the measurement of lipid levels. A slight increase was observed in intervention times in the diagnosis and implementation of a drug therapy (reperfusion) (door-to-EKG time and door-needle time) while maintaining the same mortality rates. MÉD.UIS. 2016;29(3):27-32.

Tromboprofilaxis en el paciente médico hospitalizado por medicina interna Un estudio de corte transversal / Thromboprophylaxis in the hospitalized medical patient by internal medicine A cross-sectional study

Introducción: el tromboembolismo venoso es una de las principales causas de morbimortalidad prevenible seguida de una hospitalización. Las heparinas han demostrado ser eficaces para su prevención, sin embargo se ha documentado la subutilización de estos fármacos, por lo que implementar medidas que garanticen la formulación adecuada es fundamental. En nuestra institución se han instaurado estrategias para mejorar la formulación de estos fármacos con resultados iniciales favorables, pero se desconoce el efecto a más largo plazo. Métodos: estudio descriptivo, retrospectivo de corte transversal. Se evaluaron pacientes mayores de 18 años, hospitalizados por medicina interna entre junio y noviembre de 2012. Se estimó una muestra representativa de 102 pacientes. Se identificó la formulación de la tromboprofilaxis al segundo día de hospitalización, se determinó si fue adecuada según las guías institucionales y los errores en la prescripción de la misma. Se compararon los resultados con dos mediciones previas realizadas en la institución. Resultados: de los 102 pacientes evaluados, la tromboprofilaxis fue adecuada en 63 (61,8%) e inadecuada en 39 (38.2%). Las causas más frecuentes de error fueron: formulación en pacientes de bajo riesgo 18 (46.1%) y error por omisión en 12 (30.7%) pacientes. La formulación en pacientes con indicación y sin contraindicación disminuyó de 92-82% y en pacientes sin indicación aumentó de 50-56.2%, con relación a una medida previa realizada después de la difusión de guías institucionales. Conclusiones: la tromboprofilaxis en pacientes hospitalizados por medicina interna en nuestra institución se ordena en un alto porcentaje, sin embargo debe ser mejorada. El principal error es la formulación en pacientes con riesgo bajo. La implementación de estrategias para mejorar la tromboprofilaxis logró una mejoría inicial, pero tiende a disminuir con el tiempo. Se requiere un trabajo continuado de múltiples medidas que garanticen su impacto favorable a largo plazo. (Acta Med Colomb 2015; 40: 227-233).

Introduction: venous thromboembolism is one of the major causes of preventable morbidity and mortality following a hospitalization. Heparins have proven effective for prevention; however, under utilization of these drugs has been documented, so that the implementation of measures to ensure the proper formulation is essential. Strategies to improve the formulation of these drugs have been established in our institution with favorable initial results, but the longer-term effect is unknown. Methods: descriptive, retrospective cross-sectional study. Patients over 18 years hospitalized for internal medicine between June and November 2012 were evaluated. A representative sample of 102 patients was estimated. Thromboprophylaxis formulation was identified on the second day of hospitalization and it was determined if its prescription was appropriate in accordance with the institutional guidelines as well as errors in its prescription. The results were compared with two previous measurements realized in the institution. Results: Of the 102 patients evaluated, thromboprophylaxis was adequate in 63 (61.8%) and inadequate in 39 (38.2%). The most frequent causes of error were: prescription in low-risk patients 18 (46.1%) and error of omission in 12 (30.7%) patients. The formulation in patients with an indication and without contraindication decreased from 92% to 82% and in patients with no indication increased from 50% to 56.2%, compared to a previous measurement made after the dissemination of institutional guidelines. Conclusions: thromboprophylaxis in hospitalized patients in internal medicine at our institution is organized in a high percentage, but must be improved. The main error is the formulation in patients with low risk. The implementation of strategies to improve thromboprophylaxis achieved initial improvement, but tends to decrease over time. Continued work of multiple measures to ensure their favorable long-term impact is required. (Acta Med Colomb 2015; 40: 227-233).

Optimization of door-to-electrocardiogram time within a critical pathway for the management of acute coronary syndromes at a teaching hospital in Colombia.

INTRODUCTION: Door-to-electrocardiogram (D2E) time is recognized as one of the quality parameters in the attention of acute coronary syndromes. Electrocardiogram realization within periods below 10 minutes increases the possibility to achieve quick and effective reperfusion, which has an impact on outcomes. OBJECTIVE: To describe the results of a strategy whose goal is to improve the fulfillment of the D2E deadline below 10 minutes in adults who attend the emergency service due to chest pain with clinical suspicion of acute coronary syndromes. METHODS: Before-and-after study that assesses D2E time upon the implementation of actions for the reorganization of the process of attention of the patients with chest pain within the context of the implementation of a critical pathway. RESULTS: A total of 373 patients were assessed, 204 in the before stage and 169 in the after stage. The median D2E time was 16 minutes in the before stage, in 41% of the cases it was below 10 minutes; upon the implementation of the change in the process of attention of chest pain the median was 5 minutes, with 63% of the cases below 10 minutes, exhibiting a statistically significant difference. CONCLUSIONS: The actions taken led to a lower median of D2E time and a higher percentage of patients with times below 10 minutes. However, further interventions are required to assure a higher number of patients with D2E times below 10 minutes.

Características clínicas y sociodemográficas de pacientes con anemia megaloblástica. Hospitales de San José e Infantil Universitario de San José / Clinical, social and demographic characteristics of patients with megaloblastic anemia - San José and infantil Universitario de San José hospitals

La deficiencia de vitamina B 12 es la causa más frecuente de anemia después del origen ferropénico. Objetivo: establecer el perfil sociodemográfico y clínico en anemia megaloblástica. Materiales y métodos: serie de pacientes hospitalizados con anemia megaloblástica entre enero 2010 y diciembre 2011 en los hospitales de San José e Infantil Universitario de San José, Bogotá DC. Resultados: 17 casos, 11 en hombres. Edad promedio 59 años (DE: 15.8 años, rango: 37-82), 88% casados, estrato dos 76.4%, pensionados 17%, con ingresos de dos salarios mínimos legales vigentes mensuales 94.1% y conviven con más de dos personas 75.4%. Siete pacientes (41.1%) con déficit combinado de ácido fólico y vitamina B12, de vitamina B 12 tres (17.6%) y de ácido fólico dos (14.2%). Las manifestaciones más frecuentes fueron anorexia (70.5%), piel seca (62.5%), glositis atrófica (29,4%) e ictericia (23.5%). Se observó asociación con enfermedad autoinmune en 17.6%, neoplasias de origen no hematológico 11.7% y consumo crónico de alcohol 35.3%. Conclusión: la mayoría pertenecieron a estrato socioeconómico bajo, con ingresos limitados y familias constituidas por más de dos personas. Las manifestaciones más frecuentes fueron digestivas, dermatológicas y neurológicas. Se encontró déficit combinado de vitamina B12 y ácido fólico, exclusivo de ácido fólico asociado con consumo crónico de alcohol y solo de vitamina B 12...

Vitamin B12 deficiency is the second leading cause of anemia following iron deficiency. Objective: to establish the social and demographic profile of megaloblastic anemia. Materials and Methods: series of inpatients diagnosed with mega loblastic anemia admitted to San José and Infantil Universitario de San José hospitals, Bogotá DC, between January 2010 and December 2011. Results: of the 17 cases included 11 were men; mean age was 59 years (SD: 15.8 years, range: 37-82), 88% were married, 76.4% belonged to level two socioeconomic stratum, 17% were retired, 94.1% earned two legal minimum monthly salaries and 75.4% lived with more than two family members. Seven patients (41.1%) had a combined deficiency of folic acid and vitamin B12, three (17.6%) only a vitamin B12 deficiency and two (14.2%) only a folic acid deficiency. The most frequent manifestations were anorexia (70.5%), dry skin (62.5%), atrophic glossitis (29.4%) and jaundice (23.5%). Association with an autoimmune disease was seen in 17.6%, with non-hematologic neoplasms 11.7% and with chronic alcohol abuse 35.3%. Conclusion: most patients belonged to a low socioeconomic stratum with limited income and families with more than two members. The most frequent manifestations were digestive, dermatologic and neurological disorders. Combined deficiency of vitamin B12 and folic acid, only of folic acid associated with chronic alcohol abuse and only of vitamin B12 was found...