Impact of hydrocolloid dressings in the prevention of pressure ulcers in high-risk patients: a randomized controlled trial (PENFUP).

It is uncertain whether hydrocolloid dressings, a more costly intervention than offering standard care with petrolatum, is superior to prevent pressure ulcers among hospitalized high-risk adults. Randomized, parallel-group, open-label, superiority trial with an active control group, blinded for investigators, event validators, and analysts (December 1, 2015 to December 12, 2017). Eligible patients were ≥ 18 years of age with intact skin judged as high-risk for skin ulcers (Braden scale), admitted to surgical or medical wards of two tertiary-level hospitals. Participants were randomized (1:1) to protection with hydrocolloid dressings or petrolatum. The primary outcome was the first occurrence of pressure ulcers (with post-injury photographs adjudicated by three judges) under intention-to-treat analysis. Based on prior cost analysis, and the available resources (assumed incidence of 6 ulcers/1000 patient-days in controls), inclusion of up to 1500 participants allowed to surpass a one-sided superiority threshold > 5% based on a target efficacy > 40% for dressings. We planned an economic analysis using a decision tree model based on the effectiveness of the study results from a perspective of the third payer of health care. After inclusion of 689 patients (69 events), the trial was stopped for futility after a planned interim analysis (conditional power < 0.1 for all scenarios if the trial was completed). Pressure ulcers had occurred in 34 (10.2%) patients in the intervention group [9.6 per 1000 patient-days] and 35 (9.9%) participants in the control group [7.9 per 1000 patient-days], HR = 1.07 [95% CI 0.67 to 1.71]. The estimated incremental cost for dressings (a dominated strategy) was USD 52.11 per patient. Using hydrocolloid dressings was found similar to petrolatum for preventing pressure ulcers among hospitalized high-risk patients. As it conveys additional costs, and in this study was unlikely to demonstrate enough superiority, this strategy did not overcome conventional skin care.Trial registration: ClinicalTrials.gov identifier (NCT number): NCT02565745 registered on December 1, 2015.

Access to paediatric cardiac surgery in Colombia: a population-based study.

OBJECTIVES: Globally congenital heart disease mortality is declining, yet the proportion of infant deaths attributable to heart disease rises in Colombia and other middle-sociodemographic countries. We aimed to assess the accessibility of paediatric cardiac surgery (PCS) to children <18 years of age in 2016 in the South American country of Colombia. METHODS: In Bogotá, Colombia, a multi-national team used cross-sectional and retrospective cohort study designs to adapt and evaluate 4 health system indicators at the national level: first, the population with timely geographic access to an institution providing PCS; second, the number of paediatric cardiac surgeons; third, this specialized procedure volume and its national distribution; and fourth, the 30-day perioperative mortality rate after PCS in Colombia. RESULTS: Geospatial mapping approximates 64% (n = 9 894 356) of the under-18 Colombian population lives within 2-h drivetime of an institution providing PCS. Twenty-eight cardiovascular surgeons report performing PCS, 82% (n = 23) with formal training. In 2016, 1281 PCS procedures were registered, 90% of whom were performed in 6 of the country's 32 departments. National non-risk-adjusted all-cause 30-day perioperative mortality rate after PCS was 2.73% (n = 35). CONCLUSIONS: Colombia's paediatric population had variable access to cardiac surgery in 2016, largely dependent upon geography. While the country may have the capacity to provide timely, high-quality care to those who need it, our study enables future comparative analyses to measure the impact of health system interventions facilitating healthcare equity for the underserved populations across Colombia and the Latin American region.

Chronic Obstructive Pulmonary Disease Patients Have Increased Levels of Plasma Inflammatory Mediators Reported Upregulated in Severe COVID-19.

Background: Chronic obstructive pulmonary disease (COPD) is associated with increased risk of severe COVID-19, but the mechanisms are unclear. Besides, patients with severe COVID-19 have been reported to have increased levels of several immune mediators. Methods: Ninety-two proteins were quantified in 315 plasma samples from 118 asthmatics, 99 COPD patients and 98 healthy controls (age 40-90 years), who were recruited in Colombia before the COVID-19 pandemic. Protein levels were compared between each disease group and healthy controls. Significant proteins were compared to the gene signatures of SARS-CoV-2 infection reported in the "COVID-19 Drug and Gene Set Library" and with experimentally tested protein biomarkers of severe COVID-19. Results: Forty-one plasma proteins showed differences between patients and controls. Asthmatic patients have increased levels in IL-6 while COPD patients have a broader systemic inflammatory dysregulation driven by HGF, OPG, and several chemokines (CXCL9, CXCL10, CXCL11, CX3CL1, CXCL1, MCP-3, MCP-4, CCL3, CCL4 and CCL11). These proteins are involved in chemokine signaling pathways related with response to viral infections and some, were found up-regulated upon SARS-CoV-2 experimental infection of Calu-3 cells as reported in the COVID-19 Related Gene Sets database. An increase of HPG, CXCL9, CXCL10, IL-6, MCP-3, TNF and EN-RAGE has also been experimentally detected in patients with severe COVID-19. Conclusions: COPD patients have altered levels of plasma proteins that have been reported increased in patients with severe COVID-19. Our study suggests that COPD patients have a systemic dysregulation in chemokine networks (including HGF and CXCL9) that could make them more susceptible to severe COVID-19. Also, that IL-6 levels are increased in some asthmatic patients (especially in females) and this may influence their response to COVID-19. The findings in this study depict a novel panel of inflammatory plasma proteins in COPD patients that may potentially associate with increased susceptibility to severe COVID-19 and might be useful as a biomarker signature after future experimental validation.

Quality of life in children with infrequent congenital heart defects: cohort study with one-year of follow-up.

BACKGROUND: The evidence regarding patient related outcomes in children with infrequent congenital heart defects (I-CHD) is very limited. We sought to measure quality of life (QoL) in children with I-CHD, and secondarily, to describe QoL changes after one-year of follow-up, self-reported by children and through their caregivers' perspective. METHODS: We assembled a cohort of children diagnosed with an I-CHD in a cardiovascular referral center in Colombia, between August 2016 and September 2018. At baseline and at one-year follow-up, a clinical psychology assessment was performed to establish perception of QoL. The Pediatric Quality of Life Inventory (PedsQL) 4.0 scale was used in both general and cardiac modules for patients and for their caregivers. We used a Mann-Whitney U test to compare scores for general and cardiac modules between patients and caregivers, while a Wilcoxon test was used to compared patients' and caregivers' baseline and follow-up scores. Results are presented as median and interquartile range. RESULTS: To date, QoL evaluation at one-year follow-up has been achieved in 112/157 patients (71%). Self-reported scores in general and cardiac modules were higher than the QoL perceived through their caregivers, both at baseline and after one-year of follow-up. When compared, there was no statistically significant difference in general module scores at baseline between patients (median = 74.4, IQR = 64.1-80.4) and caregivers scores (median = 68.4, IQR = 59.6-83.7), p = 0.296. On the contrary, there was a statistical difference in baseline scores in the cardiac module between patients (median = 79.6, IQR = 69.7-87.4) and caregivers (median = 73.6, IQR = 62.6-84.3), p = 0.019. At one-year of follow-up, scores for the general module between patients (median = 72.8, IQR = 59.2-85.9) and caregivers (median = 69.9, IQR = 58.1-83.7) were not statistically different (p = 0.332). Finally, a significant difference was found for cardiac module scores between patient (median = 75.0, IQR = 67.1-87.1) and caregivers (median = 73.1, IQR = 59.5-83.8), p = 0.034. CONCLUSIONS: QoL in children with I-CHD can be compromised. However, children have a better perception of their QoL when compared with their caregivers' assessments. To provide high-quality care, besides a thorough clinical evaluation, QoL directly elicited by the child should be an essential aspect in the integral management of I-CHD.

Cost-effectiveness analysis of newborn pulse oximetry screening to detect critical congenital heart disease in Colombia.

BACKGROUND: In many countries, economic assessments of the routine use of pulse oximetry in the detection of Critical Congenital Heart Disease (CCHD) at birth has not yet been carried out. CCHDs necessarily require medical intervention within the first months of life. This assessment is a priority in low and medium resource countries. The purpose of this study was to assess the cost-effectiveness (CE) relation of pulse oximetry in the detection of cases of CCHD in Colombia. METHODS: A full economic assessment of the cost-effectiveness type was conducted from the perspective of society. A decision tree was constructed to establish a comparison between newborn physical examination plus pulse oximetry, versus physical examination alone, in the diagnosis of CCHDs. The sensitivity and specificity of pulse oximetry were estimated from a systematic review of the literature; to assess resource use, micro-costing analyses and surveys were conducted. The time horizon of the economic evaluation was the first week after birth and until the first year of life. The incremental cost-effectiveness ratio (ICER) was determined and, to control for uncertainty, deterministic and probabilistic sensitivity analysis were made, including the adoption of different scenarios of budgetary impact. All costs are expressed in US dollars from 2017, using the average exchange rate for 2017 [$2,951.15 COP for 1 dollar]. RESULTS: The costs of pulse oximetry screening plus physical examination were $102; $7 higher than physical examination alone. The effectiveness of pulse oximetry plus the physical examination was 0.93; that is, 0.07 more than the physical examination on its own. The ICER was $100 for pulse oximetry screening; that is, if one wishes to increase 1% the probability of a correct CCHD diagnosis, this amount would have to be invested. A willingness to pay of $26.292 USD (direct medical cost) per probability of a correct CCHD diagnosis was assumed. CONCLUSIONS: At current rates and from the perspective of society, newborn pulse oximetry screening at 24 h in addition to physical examination, and considering a time horizon of 1 week, is a cost-effective strategy in the early diagnosis of CCHDs in Colombia.Trial registration "retrospectively registered".

Fortalecimiento de la capacidad institucional para la equidad en la investigación en salud: enseñanzas de América Latina y el Caribe

[EXTRACTO]. Actualmente se presta cada vez más atención a los determinantes políticos, económicos, ambientales y sociales de la salud. Esto ha generado una mayor demanda de investigación para la salud a nivel mundial que incluya a los países de ingresos bajos y medianos, con objeto de alcanzar los objetivos de desarrollo sostenible de las Naciones Unidas. Además del financiamiento, se necesitan suficientes recursos humanos e infraestructura para que estos países lleguen a ser asociados en un plano de igualdad con las instituciones de investigación internacionalmente reconocidas de los países de ingresos altos que establecen las agendas de investigación, y para garantizar que el programa de investigación mundial refleje sus necesidades. Las limitaciones en la capacidad de investigación y las grandes disparidades existentes entre los países de ingresos altos y los de ingresos bajos y medianos en cuanto a su capacidad de producir y usar la investigación para la salud han contribuido a producir una falta de evidencia que permita fundamentar la práctica clínica y orientar las políticas sanitarias regionales y mundiales. Esto ha perpetuado las desigualdades en la salud...

[EXTRACTO]. Existe atualmente um maior reconhecimento dos determinantes políticos, econômicos, ambientais e sociais da saúde. A consequência disso foi um aumento da demanda por pesquisa em saúde global, com participação dos países de baixa e média renda, para cumprir os objetivos de desenvolvimento sustentável das Nações Unidas. Além de financiamento, são necessários recursos humanos e infraestrutura suficientes para que esses países se tornem parceiros em igualdade de condições com instituições de pesquisa internacionalmente reconhecidas em países de alta renda que definem as agendas de pesquisa e cuidam para que o programa global de pesquisa em saúde reflita suas necessidades. A limitada capacidade de pesquisa e as grandes disparidades entre países de alta renda e países de baixa e média renda no tocante à capacidade de produzir e usar pesquisas para a saúde contribuíram para a falta de evidências para informar a prática e orientar as políticas de saúde regionais e globais, o que perpetuou as desigualdades em saúde...

Attributed costs of health care-associated infections in a Colombian hospital, 2011- 2015 / Costos atribuidos a las infecciones asociadas con la atención en salud en un hospital de Colombia, 2011-2015

Introduction: The cost analysis of infections associated with health care represents a challenge for the health system in Colombia given their determinants. Objective: To determine the factors related to the increase and variability in the costs of hospital care for infections associated with health care in a fourth-level hospital in Bogotá from 2011 to 2015. Materials and methods: The costs of the care for 292 patients were analyzed including each of the activities carried out since the suspicion of the infectious disease until its resolution. These costs were standardized to the value of the Instituto de Seguros Sociales tariff manual adjusted by the annual consumer price index for health until 2014. The factors related to the increase in management costs were identified using a conditional logistic regression model. Results: A hospital stay of nine days or more prior to the infection was a factor associated with the increase of direct costs in the management of infections associated with health care (OR=2.06; 95% CI: 1.11-3.63). The median cost of the infections was COP $1.190.879. The antibiotic treatment represented 41% of the total value of the treatment, followed by laboratory tests with a cost equivalent to 13.5%. Conclusions: We found a relationship between the cost of the management of infections associated with health care and the hospital stay prior to their appearance. The pathological antecedents of the patients were not related to the increase in the cost.

Introducción. El análisis de los costos derivados de las infecciones asociadas con la atención en salud representa un desafío para el sistema de salud en Colombia dados sus factores determinantes. Objetivo. Determinar los factores relacionados con el aumento y la variabilidad de los costos de la atención hospitalaria por las infecciones asociadas con la atención en salud en un hospital de cuarto nivel de Bogotá, entre el 2011 y el 2015. Materiales y métodos. Se analizaron los costos de la atención de 292 pacientes, los cuales se estimaron para cada una de las actividades realizadas desde el momento de sospechar el cuadro infeccioso hasta su resolución. Dichos costos se estandarizaron según el valor del manual tarifario del Instituto de Seguros Sociales, ajustándolos por el índice de precios al consumidor para salud hasta el año 2014. Se determinaron los factores relacionados con el aumento del costo del manejo mediante un modelo logístico condicional. Resultados. La estancia hospitalaria de nueve días o más antes de la infección, se asoció con el aumento del costo directo del manejo de las infecciones relacionadas con la atención en salud (odds ratio, OR=2,06; IC95% 1,11-3,63). El costo medio del manejo de las infecciones fue de COP $1.190.879. Los antibióticos representaron el 41 % del valor total del tratamiento, seguidos de los exámenes de laboratorio, con un costo equivalente al 13,5 %. Conclusión. Se encontró una relación entre el costo del manejo de las infecciones asociadas con la atención en salud y la estancia hospitalaria previa a su aparición. Los antecedentes patológicos de los pacientes no se relacionaron con el aumento de los costos.

Postoperative atrial fibrillation: evaluation of its economic impact on the costs of cardiac surgery

Abstract Objective: The objective of this study was to calculate the direct costs of postoperative atrial fibrillation (POAF) in a high-complexity cardiovascular hospital. Methods: We performed a cost analysis with a pairwise-matched design. Twenty-two patients with POAF and 22 patients without this complication were included. Pair-matching was performed (1:1) based on the following criteria: identical type of surgery, similar EuroSCORE II values, and absence of any other postoperative complication. Results: The total hospital cost was significantly higher in the POAF group than in the non-POAF group (US$ 10,880 [± 2,688] vs. US$ 8,856 [± 1,782], respectively, for each patient; P=0.005). This difference was attributable to postoperative costs (US$ 3,103 [± 1,552] vs. US$ 1,238 [± 429]; P=0.0001) for patients with or without POAF, respectively. The median postoperative lengths of stay were 9 (range 5-17) and 5 (3-9) days for patients with and without POAF (P=0.032), respectively. Preoperatively, no differences were found in the EuroSCORE II values (median 1.7 vs. 1.6, respectively; P=0.91) or direct costs (US$ 1,127 vs. US$ 1,063, respectively; P=0.56) between POAF and non-POAF groups. Conclusion: POAF generates a high economic burden in the overall costs of cardiac surgery, and our results reveal the differential contribution of each of the evaluated factors. This information, which was previously unavailable in this setting, is essential for the development of more effective prevention strategies.

Postoperative Atrial Fibrillation: Evaluation of its Economic Impact on the Costs of Cardiac Surgery.

OBJECTIVE: The objective of this study was to calculate the direct costs of postoperative atrial fibrillation (POAF) in a high-complexity cardiovascular hospital. METHODS: We performed a cost analysis with a pairwise-matched design. Twenty-two patients with POAF and 22 patients without this complication were included. Pair-matching was performed (1:1) based on the following criteria: identical type of surgery, similar EuroSCORE II values, and absence of any other postoperative complication. RESULTS: The total hospital cost was significantly higher in the POAF group than in the non-POAF group (US$ 10,880 [± 2,688] vs. US$ 8,856 [± 1,782], respectively, for each patient; P=0.005). This difference was attributable to postoperative costs (US$ 3,103 [± 1,552] vs. US$ 1,238 [± 429]; P=0.0001) for patients with or without POAF, respectively. The median postoperative lengths of stay were 9 (range 5-17) and 5 (3-9) days for patients with and without POAF (P=0.032), respectively. Preoperatively, no differences were found in the EuroSCORE II values (median 1.7 vs. 1.6, respectively; P=0.91) or direct costs (US$ 1,127 vs. US$ 1,063, respectively; P=0.56) between POAF and non-POAF groups. CONCLUSION: POAF generates a high economic burden in the overall costs of cardiac surgery, and our results reveal the differential contribution of each of the evaluated factors. This information, which was previously unavailable in this setting, is essential for the development of more effective prevention strategies.

Costos atribuidos a las infecciones asociadas con la atención en salud en un hospital de Colombia, 2011-2015 / Attributed costs of health care-associated infections in a Colombian hospital, 2011- 2015

Resumen Introducción. El análisis de los costos derivados de las infecciones asociadas con la atención en salud representa un desafío para el sistema de salud en Colombia dados sus factores determinantes. Objetivo. Determinar los factores relacionados con el aumento y la variabilidad de los costos de la atención hospitalaria por las infecciones asociadas con la atención en salud en un hospital de cuarto nivel de Bogotá, entre el 2011 y el 2015. Materiales y métodos. Se analizaron los costos de la atención de 292 pacientes, los cuales se estimaron para cada una de las actividades realizadas desde el momento de sospechar el cuadro infeccioso hasta su resolución. Dichos costos se estandarizaron según el valor del manual tarifario del Instituto de Seguros Sociales, ajustándolos por el índice de precios al consumidor para salud hasta el año 2014. Se determinaron los factores relacionados con el aumento del costo del manejo mediante un modelo logístico condicional. Resultados. La estancia hospitalaria de nueve días o más antes de la infección, se asoció con el aumento del costo directo del manejo de las infecciones relacionadas con la atención en salud (odds ratio, OR=2,06; IC95% 1,11-3,63). El costo medio del manejo de las infecciones fue de COP $1.190.879. Los antibióticos representaron el 41 % del valor total del tratamiento, seguidos de los exámenes de laboratorio, con un costo equivalente al 13,5 %. Conclusión. Se encontró una relación entre el costo del manejo de las infecciones asociadas con la atención en salud y la estancia hospitalaria previa a su aparición. Los antecedentes patológicos de los pacientes no se relacionaron con el aumento de los costos.

Abstract Introduction: The cost analysis of infections associated with health care represents a challenge for the health system in Colombia given their determinants. Objective: To determine the factors related to the increase and variability in the costs of hospital care for infections associated with health care in a fourth-level hospital in Bogotá from 2011 to 2015. Materials and methods: The costs of the care for 292 patients were analyzed including each of the activities carried out since the suspicion of the infectious disease until its resolution. These costs were standardized to the value of the Instituto de Seguros Sociales tariff manual adjusted by the annual consumer price index for health until 2014. The factors related to the increase in management costs were identified using a conditional logistic regression model. Results: A hospital stay of nine days or more prior to the infection was a factor associated with the increase of direct costs in the management of infections associated with health care (OR=2.06; 95% CI: 1.11-3.63). The median cost of the infections was COP $1.190.879. The antibiotic treatment represented 41% of the total value of the treatment, followed by laboratory tests with a cost equivalent to 13.5%. Conclusions: We found a relationship between the cost of the management of infections associated with health care and the hospital stay prior to their appearance. The pathological antecedents of the patients were not related to the increase in the cost.

Challenges to the improvement of Colombian medical brigades aimed at the diagnosis of congenital heart disease: A qualitative approach.

Qualitative research of brigades and the family experience of congenital heart disease is of current interest and has been previously neglected. This study aimed to explore the social factors conditioning outcomes of paediatric cardiology care in the setting of Colombian medical brigades and to identify feasible strategies to improve the experience of the beneficiary populations. Participants were selected using purposeful sampling. Semi-structured interviews were conducted with members of logistic and health care teams, caregivers and custodians of beneficiary children of the Programme. The data collected provided an understanding of the health culture, social background, household and intrafamily dynamics. The outcomes of the Programme are influenced by sociocultural dynamics such as communication gaps and the socioeconomic status of the beneficiary populations. Findings may be specific to brigades, but also cross-relevant to any family experience of a new diagnosis of Congenital Heart Disease (CHD) communicating with healthcare professionals. It is important to foresee the role and further development of the Programme. Recommendations are provided suggesting innovative work by means of telemedicine and other sociocultural measures to reduce healthcare inequity and strengthen comprehensive healthcare programmes.

Clinical and economic outcomes associated with malnutrition in hospitalized patients.

BACKGROUND & AIMS: Hospitalized patients show a high rate of malnutrition, which is associated with poor patient outcomes and high healthcare costs. However, relatively few studies have investigated the association between clinical and economic outcomes and malnutrition in hospitalized patients, particularly those with cardiac and pulmonary conditions. METHODS: This multicenter prospective observational cohort study included 800 patients hospitalized at four Colombian hospitals with a diagnosis of congestive heart failure, acute myocardial infarction, community-acquired pneumonia, or chronic obstructive pulmonary disease. All patients were screened for malnutrition using the Malnutrition Screening Tool (MST). A descriptive analysis of baseline variables was followed by multivariate analysis and inverse probability weighting (IPW) to compare the clinical outcomes, i.e., length of stay (LOS), mortality, and readmission, and hospital costs associated with a positive MST result. RESULTS: The prevalence of a positive MST result was 24.62% (n = 197) and was more common in patients with older age and greater comorbidities. Multivariate analysis controlling for age, gender, healthcare plan, university degree, hospitalization, entrance disease and Charlson co-morbidity index showed that a positive MST result was associated with increased LOS (1.43 ± 0.61 days) and both in-hospital mortality (odds ratio, 2.39) and global mortality (odds ratio, 2.52). IPW analysis confirmed the association between a positive MST result and increased hospital LOS and 30-day mortality, as well as a relative increase of 30.13% in the average cost associated with hospitalization. CONCLUSIONS: This study of hospital inpatients demonstrated a high burden of malnutrition at the time of hospital admission, which negatively impacted LOS and mortality and increased the costs of hospitalization. These findings underscore the need for improved diagnosis and treatment of hospital malnutrition to improve patient outcomes and reduce healthcare costs.

Factors associated with delayed cardiac tamponade after cardiac surgery.

CONTEXT: Cardiac tamponade (CT) following cardiac surgery is a potentially fatal complication and the cause of surgical reintervention in 0.1%-6% of cases. There are two types of CT: acute, occurring within the first 48 h postoperatively, and subacute or delayed, which occurs more than 48 h postoperatively. The latter does not show specific clinical signs, which makes it more difficult to diagnose. The factors associated with acute CT (aCT) are related to coagulopathy or surgical bleeding, while the variables associated with subacute tamponade have not been well defined. AIMS: The primary objective of this study was to identify the factors associated with the development of subacute CT (sCT). SETTINGS AND DESIGN: This report describes a case (n = 80) and control (n = 160) study nested in a historic cohort made up of adult patients who underwent any type of urgent or elective cardiac surgery in a tertiary cardiovascular hospital. Methods: The occurrence of sCT was defined as the presence of a compatible clinical picture, pericardial effusion and confirmation of cardiac tamponade during the required emergency intervention at any point between 48 hours and 30 days after surgery. All factors potentially related to the development of sCT were taken into account. STATISTICAL ANALYSIS USED: For the adjusted analysis, a logistical regression was constructed with 55 variables, including pre-, intra-, and post-operative data. RESULTS: The mortality of patients with sCT was 11% versus 0% in the controls. Five variables were identified as independently and significantly associated with the outcome: pre- or post-operative anticoagulation, reintervention in the first 48 h, surgery other than coronary artery bypass graft, and red blood cell transfusion. CONCLUSIONS: Our study identified five variables associated with sCT and established that this complication has a high mortality rate. These findings may allow the implementation of standardized follow-up measures for patients identified as higher risk, leading to either early detection or prevention.

Inactivity and Its Associated Factors in Adults Scheduled for Noncardiac Surgery: The PAMP Phase I Study.

PURPOSE: The aim of this study was to determine the prevalence of physical inactivity and its associated factors in adult patients admitted to hospital for noncardiac surgery. DESIGN: Cross-sectional study. METHODS: Five hundred able-bodied patients (age ≥45 years) admitted to hospital, also participants in the VISION study, were recruited before noncardiac surgery. The physical activity level (PAL) was assessed with the International Physical of Activity Questionnaire. Logistic regression analysis was conducted to determine the associations between a number of predetermined factors and physical inactivity. FINDINGS: Overall, 59.8% were inactive. Factors associated with inactivity included age, assistance with activities of daily living, and insulin-dependent diabetes. CONCLUSION: A substantial number of patients scheduled for noncardiac surgery are inactive. Elderly patients, those needing assistance, and those with long-lasting diabetes may benefit from PAL assessment before surgery. CLINICAL RELEVANCE: Healthcare providers should identify PALs and monitor for known risk factors to prepare patients for surgical procedures.

Mortalidad observada versus esperada en una red de unidades de diálisis en Colombia / Observed versus expected mortality in a network of dialysis units in Colombia

Resumen Antecedentes: la mortalidad en diálisis es uno de los principales indicadores de gestión clínica y se ve influenciada por diversos factores sociodemográficos y clínicos. Objetivos: calcular la mortalidad observada versus la esperada en las unidades de diálisis de la red de RTS en Colombia. Métodos: cohorte histórica de pacientes mayores de 18 años, prevalentes en diálisis entre el 1 de enero y el 31 de diciembre de 2012, de 51 unidades renales de la red Renal Therapy Services (RTS). Se calculó la razón estandarizada de mortalidad (REM) siguiendo la metodología propuesta por la Universidad de Michigan Centro de Costos y Epidemiologic Renal (UM-KECC); se implementó un modelo de supervivencia de riesgos proporcionales de Cox en dos etapas, la primera estimó los parámetros asociados con las variables explicativas y la segunda estandarizó los resultados. Resultados: se evaluaron 9798 pacientes, 4125 (42.1%) fueron mujeres, la media de edad fue de 59 años (DE=15.6). Se observaron 1253 eventos de muerte (12.7%). El modelo arrojó un valor de 1067 muertes esperadas, con un valor estimado de REM de 1.17 (IC95%: 1.11-1.24). La REM fue mayor para pacientes diabéticos 1.28 (IC95%:1.19-1.38) y mujeres (1.36 (IC95%: 1.25-1.48); y varió significativamente por zona del país (1.11 a 2.0). Conclusiones: encontramos diferencias importantes en la REM según sexo, presencia de diabetes y por zonas del país. Se requiere mediante nuevos estudios entender mejor la influencia de estas y otras variables sobre el fenómeno de mortalidad en diálisis en nuestro contexto. (Acta Med Colomb 2017; 42: 106-111).

Abstract Background: mortality in dialysis is one of the main indicators of clinical management and is influenced by various socio-demographic and clinical factors. Objectives: to calculate the observed versus expected mortality in the dialysis units of the RTS network in Colombia. Methods: a historical cohort of patients older than 18 years, prevalent on dialysis between January 1 and December 31, 2012, of 51 renal units of the Renal Therapy Services (RTS) network. The standardized mortality ratio (SMR) was calculated following the methodology proposed by the University of Michigan Center for Costs and Renal Epidemiology (UM-KECC); a Cox proportional hazards survival model was implemented in two stages, the first estimated the parameters associated with the explanatory variables and the second standardized the results. Results: 9798 patients were evaluated, 4125 (42.1%) were women. The mean age was 59 years (SD = 15.6). There were 1253 death events (12.7%). The model gave a value of 1067 expected deaths, with an estimated SMR value of 1.17 (95% CI: 1.11-1.24). SMR was greater for diabetic patients 1.28 (95% CI: 1.19-1.38) and women (1.36 (95% CI: 1.25-1.48)) and it varied significantly depending on the region of the country (1.11 to 2.0). Conclusions: important differences in SMR according to sex, presence of diabetes and by regions of the country were found. Further studies are required to better understand the influence of these and other variables on the mortality phenomenon in dialysis in our context. (Acta Med Colomb 2017; 42: 106-111).

Diferencias regionales en cardiopatías congénitas / Regional differences in congenital heart disease

Resumen Objetivo: Estimar la frecuencia relativa de las cardiopatías congénitas detectadas en el periodo post-natal en población pediátrica de once Departamentos de Colombia, y comparar cuáles son más frecuentes por Departamentos y regiones del país. Métodos: Se llevó a cabo un estudio observacional de corte transversal, teniendo como fuente de información la base de datos recolectada entre los años 2008 y 2013 durante las brigadas de cardiología pediátrica para la detección de cardiopatías congénitas, realizadas por la Fundación Cardioinfantil-Instituto de Cardiología, en alianza con entidades civiles y gubernamentales de cada Departamento. Resultados: Se analizaron datos de 5.900 sujetos, estudiados con historia clínica y ecocardiograma. Se detectaron 3.309 (56,1%) casos de cardiopatía congénita, 54,3% correspondientes al género masculino. En el ámbito nacional, las cardiopatías más frecuentes en orden de frecuencia fueron: comunicación interventricular, obstrucción del tracto de salida del ventrículo derecho, comunicación interauricular, ductus arterioso persistente y obstrucción del tracto de salida del ventrículo izquierdo. Se encontró diferencia estadísticamente significativa en la comparación de la distribución de las cardiopatías congénitas más frecuentes (p < 0,0001), como también diferencias al comparar la distribución de estas cinco cardiopatías entre las regiones, de la siguiente manera: entre la región Caribe y Andina (p < 0,0001), Caribe y Pacífico (p < 0,0001), Caribe y Orinoquia (p = 0,0024), Andina y Pacífico (p = 0,0015), Andina y Orinoquia (p = 0,0068), Pacífico y Orinoquia (p = 0,0001). Conclusiones: Existen diferencias significativas en la distribución de las cardiopatías congénitas post-natales más frecuentes por regiones del país, que no han sido reportadas con anterioridad en Colombia ni en Latinoamérica, y que no parecen atribuibles al rol del azar.

Abstract Motivation: To estimate the relative frequency of congenital heart diseases detected during the postnatal period in a pediatric population of eleven Colombian departments, and to compare which ones are more frequent according to the country's departments and regions. Methods: A cross-sectional observational study was conducted, using as an information source the databased collected between 2008 and 2013 during the pediatric cardiology brigades organised by The Cardioinfantil Foundation-Institute of Cardiology, in alliance with civil and government entities in each department. Results: Data from 5,900 individuals were analysed, studied with their medical records and echocardiogram. 3,309 (56%) of congenital heart disease were detected, 54.3% of which were for male patients. Within the national range, the most common congenital heart diseases according to their frequency were: ventricular septal defect, right ventricular outflow tract obstruction, atrial septal defect, persistent ductus arteriosus and left ventricular outflow tract obstruction. There was a statistically significant difference in the comparison of the distribution of the most frequent congenital heart diseases (p < 0.0001), as there were differences when comparing the distribution of these five conditions within regions, as follows: Caribbean and Andean (p < 0.0001), Caribbean and Pacific (p < 0.0001), Caribbean and Orinoquía (p = 0,0024), Andean and Pacific (p = 0.0015), Andean and Orinoquía (p = 0.0068), Pacific and Orinoquía (p = 0.0001). Conclusions: Significant differences exist in the distribution of the most frequent postnatal congenital heart diseases within the different regions of the country. These have never been reported previously neither in Colombia nor in Latin America, and they do not seem attributable to chance.

Endoscopic subcutaneous component separation as an adjunct to abdominal wall reconstruction.

BACKGROUND: Proper defect closure during abdominal wall reconstruction (AWR) is a key to improving cosmetic and functional results, and reducing morbidity. We have completed the initial prospective evaluation of a technique we previously described and published: endoscopic subcutaneous anterior component separation (ACS) as an adjunct to mainly laparoscopic AWR. We now present the long-term clinical and imaging follow-up results. STUDY DESIGN: Data were prospectively collected over a 3-year period (2012-2015) on patients who underwent AWR with endoscopic ACS. Inclusion criteria included the following: defects of 6-15 cm that are longer than wider; no skin dystrophy; no loss of domain; no active infection; no previous multiple, complex repairs; no previous multiple mesh repairs; and no high probability of severe adhesions. All patients were followed up clinically at 3, 6, and 12 months postoperatively and then annually. All patients underwent CT scanning of the abdominal wall (sagittal, axial, coronal, and 3D reconstruction) at 3 months and 1 year postoperatively and then annually. RESULTS: Twenty consecutive patients underwent adjunctive endoscopic ACS: 17 laparoscopic AWRs, 2 open repairs, and 1 hybrid repair. Up to 38 months (mean 21 months) of follow-up, there were no ventral hernia recurrences or de novo hernias at the ACS site. One patient experienced partial primary closure failure. Morbidity consisted in one case each of hematoma, seroma, and transient neuralgia. Cosmetic results and patient satisfaction were excellent. CONCLUSION: We confirmed that endoscopic subcutaneous ACS is a safe, effective, reliable, reproducible technique that facilitates primary closure of defects during AWR in selected patients.

Perioperative Aspirin for Prevention of Venous Thromboembolism: The PeriOperative ISchemia Evaluation-2 Trial and a Pooled Analysis of the Randomized Trials.

BACKGROUND: The PeriOperative ISchemia Evaluation-2 (POISE-2) trial compared aspirin with placebo after noncardiac surgery. METHODS: The authors randomly assigned 10,010 patients undergoing noncardiac surgery to receive 200 mg aspirin or placebo 2 to 4 h before surgery and then 100 mg aspirin daily or placebo daily for up to 30 days after surgery. Herein, the authors report the effect of aspirin on venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, as well as an updated pooled analysis of randomized trials of antiplatelet therapy for VTE prevention in noncardiac surgery patients. RESULTS: Six thousand five hundred forty-eight patients (65.4%) received anticoagulant prophylaxis. VTE occurred in 53 patients (1.1%) allocated to aspirin and in 60 patients (1.2%) allocated to placebo (hazard ratio, 0.89; 95% CI, 0.61 to 1.28). Major or life-threatening bleeding occurred in 312 patients (6.3%) allocated to aspirin and in 256 patients (5.1%) allocated to placebo (hazard ratio, 1.22; 95% CI, 1.04 to 1.44). Concomitant use of anticoagulant prophylaxis did not modify the effect of aspirin on VTE or bleeding. Pooled analysis of the POISE-2 and Pulmonary Embolism Prevention trials demonstrated that symptomatic VTE occurred in 173 (1.3%) of 13,724 patients allocated to aspirin and in 246 (1.8%) of 13,730 patients allocated to placebo (odds ratio, 0.71; 95% CI, 0.56 to 0.89; heterogeneity P = 0.27; I = 17%); the impact of aspirin was very similar in those who did and did not receive pharmacologic prophylaxis. Pooled estimates for symptomatic VTE were similar to the pooled estimates for any deep vein thrombosis and pulmonary embolism from the POISE-2 trial, Pulmonary Embolism Prevention trial, and the Antiplatelet Trialists' Collaboration meta-analysis. CONCLUSIONS: Aspirin in the POISE-2 trial did not reduce VTE, but two thirds of patients received anticoagulant prophylaxis, there were few VTE events, and results were consistent with a wide range of aspirin effects. A pooled analysis of the randomized trials demonstrates evidence for the efficacy of aspirin for VTE prevention in hospitalized surgical patients.