Adherencia y calidad de vida en pacientes con fibrilación auricular e insuficiencia cardíaca anticoagulados con Apixaban

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Introduction: Atrial fibrillation (AF) is the most common cardiac arrhythmia in patients with heart failure (HF), regardless of ejection fraction, leading to a greater risk of thromboembolic complications. Anticoagulation is one of the fundamental pillars in the treatment of AF, and prior to this, it is recommended to evaluate the embolic risk using the CHA2DS2-VASc score and the bleeding risk with the HAS-BLED score. There are two pharmacological groups of oral anticoagulants (OACs), vitamin K antagonists (VKAs), and direct oral anticoagulants (DOACs). Both groups have advantages and disadvantages in their use. VKAs require frequent monitoring to achieve INR levels within range, a greater number of drug and dietary interactions, leading to lower adherence, satisfaction, and quality of life. Likewise, scientific evidence supports the non-inferiority of DOACs versus VKAs, being recommended in recent clinical practice guidelines for the prevention of thrombotic events in all patients with AF except in cases where moderate to severe mitral stenosis or mechanical valve replacement coexist. To date, there are no published studies that assess adherence and impact on quality of life with the use of DOACs in HF with AF. Therefore, the objective of this research is to observe changes in adherence and quality of life of patients who were switched from VKA to DOAC, describing the occurrence of thrombotic or hemorrhagic events. Methodology: Quasi-experimental, prospective, longitudinal study. All patients over 18 years of age with AF without mechanical valve prosthesis or moderate/severe mitral stenosis, anticoagulated with warfarin with therapeutic range time (TTR) ≤65% and SAMe-T2R ≥2 were included. The Morisky questionnaire was administered to evaluate adherence, and the Anti-Clot Treatment Scale was used to evaluate satisfaction and quality of life. Thrombotic and hemorrhagic risk was evaluated by CHA2DS2-VASc and HAS-BLED. The questionnaires were applied using warfarin and the same questionnaires were repeated after replacing with DOAC for convenience, specifically apixaban. Statistical analysis was performed using the Kolmogorov-Smirnov test, Cochrane Q test, ANOVA, and STATAv.15.0. Results: 43 patients, 31 of whom were male, 100% had CHA2DS2-VASC >2, 37% had HAS-BLED >3, and 62.8% had SAMe-TT2R2 >2. There was a statistically significant difference (p<0.001) in relation to the use of apixaban in quality of life, disease burden, and positive impact. No thrombotic or hemorrhagic events were observed with the use of apixaban. Conclusions: A statistically significant difference was observed in adherence, satisfaction, and quality of life with the use of apixaban, without thrombotic or hemorrhagic events.

Introdução: A fibrilação atrial (FA) é a arritmia cardíaca mais comum em pacientes com insuficiência cardíaca (IC), independentemente da fração de ejeção, o que leva a um maior risco de complicações tromboembólicas. A anticoagulação é um dos pilares fundamentais no tratamento da FA e, antes disso, é recomendado avaliar o risco embólico usando o escore CHA2DS2-VASc e o risco de sangramento com o escore HAS-BLED. Existem dois grupos farmacológicos de anticoagulantes orais (AOs): os antagonistas da vitamina K (AVKs) e os anticoagulantes orais diretos (DOACs). Ambos os grupos têm vantagens e desvantagens em seu uso. Os AVKs exigem monitoramento frequente para alcançar níveis de RNI dentro da faixa, um maior número de interações medicamentosas e alimentares, levando a menor adesão, satisfação e qualidade de vida. Da mesma forma, a evidência científica suporta a não inferioridade dos DOACs em relação aos AVKs, sendo recomendados nas diretrizes recentes de prática clínica para a prevenção de eventos trombóticos em todos os pacientes com FA, exceto nos casos em que coexistem estenose mitral moderada a grave ou substituição valvar mecânica. Até o momento, não há estudos publicados que avaliem a aderência e o impacto na qualidade de vida com o uso de DOACs em IC com FA. Portanto, o objetivo desta pesquisa é observar mudanças na adesão e qualidade de vida de pacientes que mudaram de AVK para DOAC, descrevendo a ocorrência de eventos trombóticos ou hemorrágicos. Metodologia: Estudo quase-experimental, prospectivo e longitudinal. Foram incluídos todos os pacientes com mais de 18 anos de idade com FA sem prótese valvar mecânica ou estenose mitral moderada/grave, anticoagulados com varfarina com tempo de alcance terapêutico (TTR) ≤65% e SAMe-T2R ≥2. O questionário Morisky foi administrado para avaliar a adesão, e a Escala de Tratamento Anticoagulante foi usada para avaliar a satisfação e qualidade de vida. O risco trombótico e hemorrágico foi avaliado pelo escore CHA2DS2-VASc e HAS-BLED. Os questionários foram aplicados usando varfarina e os mesmos questionários foram repetidos após a substituição por DOAC por conveniência, especificamente apixabana. A análise estatística foi realizada usando o teste de Kolmogorov-Smirnov, teste Q de Cochrane, ANOVA e STATAv.15.0. Resultados: Foram incluídos 43 pacientes, sendo 31 do sexo masculino. Todos os pacientes apresentavam CHA2DS2-VASC >2, 37% tinham HAS-BLED >3 e 62,8% tinham SAMe-TT2R2 >2. Foi observada uma diferença estatisticamente significativa (p<0,001) no que diz respeito ao uso de apixabana na qualidade de vida, carga da doença e impacto positivo. Não foram observados eventos tromboembólicos ou hemorrágicos com o uso de apixabana. Conclusões: Foi observada uma diferença estatisticamente significativa na adesão, satisfação e qualidade de vida em relação ao uso de apixabana, sem eventos tromboembólicos ou hemorrágicos.

Incidence, Mortality and Survival of Pediatric Cancer in Uruguay 2011-2015

Introduction: Childhood cancer is a small proportion of all cancers but is still a major public health problem. Objective: To describe the 5-year incidence and mortality rates and net survival of childhood cancer in Uruguay. Method: Data on all malignant tumors diagnosed in children aged 0-14 were included for the period 2011-2015, obtained from the National Pediatric Registry of Cancer and from the Ministry of Health Mortality Registry, classified according to the International Classification of Childhood Cancer (ICCC-3). Information on the total population was obtained from national census records. Follow up was made until December 2020. Results: The standardized incidence rate was 128/million children per year. The distribution of the disease was similar to developed countries. The overall mortality rate was 28.2/million, with a net overall survival of 79.6% for the total population. Conclusion: Childhood cancer incidence in Uruguay is similar to developed countries. Progress in diagnosis and care have improved survival immensely, but efforts must continue to keep this trend and ameliorate the outcomes.

Introdução: O câncer em crianças representa uma pequena proporção de todos os cânceres, mas continua a ser um importante problema de saúde pública. Objetivo: Descrever a incidência e a mortalidade, bem como a sobrevida do câncer infantil no Uruguai por um período de cinco anos. Método: Foram incluídos todos os tumores malignos diagnosticados em crianças de 0 a 14 anos de 2011 a 2015. Os dados foram obtidos do Registro Nacional de Câncer e dos Registros de Mortalidade do Ministério da Saúde. Os casos foram classificados de acordo com a International Classification of Childhood Cancer (ICCC-3). A informação total sobre a população foi obtida a partir de registros do censo nacional. O acompanhamento foi feito até dezembro de 2020. Resultados: A taxa de incidência padronizada foi de 128/milhão de crianças por ano. A distribuição foi semelhante à dos países industrializados. A taxa de mortalidade global foi de 28,2/milhão, com sobrevida global líquida de 79,6% para a população total. Conclusão: A incidência de câncer infantil no Uruguai é semelhante à dos países desenvolvidos. Os avanços no diagnóstico e no atendimento melhoraram substancialmente a sobrevida, mas os esforços devem continuar para se obter melhores resultados.

Introducción: El cáncer en los niños constituye una pequeña proporción de todos los cánceres pero continúa siendo un importante problema de salud pública. Objetivo: Describir la incidencia y mortalidad, así como la sobrevida neta del cáncer infantil en nuestro país durante cinco años. Método: Se incluyeron todos los tumores malignos diagnosticados en niños entre 0 y 14 años desde 2011 a 2015. Los datos se obtuvieron del Registro Nacional del Cáncer así como de los Registros de Mortalidad del Ministerio de Salud. Los casos se clasificaron de acuerdo con International Classification of Childhood Cancer (ICCC-3). La información de la población total fue obtenida de los registros nacionales de censo. El seguimiento se hizo hasta diciembre de 2020. Resultados: La tasa de incidencia estandarizada fue de 128/millón de niños por año. La distribución fue similar a la de los países industrializados. La tasa de mortalidad global fue de 28,2/millón, con una sobrevida global neta de 79,6% para el grupo total. Conclusión: La incidencia de cáncer infantil en Uruguay es similar a la de los países desarrollados. Los avances en el diagnóstico y el cuidado han mejorado notablemente la sobrevida, pero se deben continuar los esfuerzos para seguir mejorando los resultados.

High Risk Neuroblastoma in Uruguay. Where are we? / Neuroblastoma de Alto Riesgo en Uruguay. ¿Dónde estamos? / Neuroblastoma de Alto Risco no Uruguai. Onde estamos?

Introdução: El neuroblastoma es el tumor sólido extracraneal más frecuente en niños. Aproximadamente el 50 % de los pacientes son clasificados como de alto riesgo, con base en características clínicas, biológicas e histológicas. Objetivo: Describir a la población asistida en el Centro Hemato-Oncológíco Pediátrico (CHOP) del Centro Hospitalario Pereira Rossell (CHPR) con diagnóstico de neuroblastoma de alto riesgo, su tratamiento y sobrevida. Método: Estudio descriptivo y retrospectivo de todos los pacientes con neuroblastoma de alto riesgo diagnosticados en el CHOP entre el 2001 y el 2015. En el CHOP se ubica el Registro Nacional de Cáncer Pediátrico, así como también el Archivo de Historias Clínicas de todos los pacientes. Los datos son recolectados y analizados por el sector de estadística. Resultados: Se diagnosticaron 35 pacientes, de los cuales 20 (57%) eran varones con mediana de edad de 36,6 meses (5-93), localización suprarrenal 23 (66%) y 100% estadio IV. Metástasis, médula ósea y hueso: 27 (71%). Treinta y tres pacientes recibieron autotransplante de progenitores hematopoyéticos (TPH) (94%). Estatus previo a TPH, remisión completa: 19 (58 %), remisión parcial: 14 (42%). Mortalidad relacionada al tratamiento: 15 % y de recaídas: 68 %. Mediana de tiempo de recaída: 15 meses (3-52). La probabilidad de sobrevida global y sobrevida libre de eventos a 5 años fue de 37,8% ± 8,4 y 23,8% ± 7,3 (mediana de seguimiento 40 meses). Conclusión: A pesar del tratamiento intensivo y de las medidas de soporte adecuadas, el pronóstico en los niños con neuroblastoma de alto riesgo sigue siendo pobre en nuestro país. Es necesario incorporar nuevas estrategias terapéuticas aún no disponibles en nuestro medio.

Introduction: Neuroblastoma is the most common extracranial solid tumor in children. Approximately 50% of patients are classified as high risk on the basis of clinical, biological, and histological characteristics. Objective: To describe the population of patients diagnosed with high-risk neuroblastoma at the Centro Hemato-Oncológíco Pediátrico (CHOP, Center for Pediatric Hematology and Oncology) of the Centro Hospitalario Pereira Rossell (CHPR, Pereira Rossell Hospital), in terms of their treatment and survival. Method: Descriptive, retrospective study of all patients diagnosed with highrisk neuroblastoma at the CHOP between 2001 and 2015. The National Registry of Pediatric Cancer is located at the CHOP, as is the Archive of Patient Clinical Histories. The data are collected and analyzed by the statistics sector. Results: Among the 35 patients diagnosed, 20 (57%) were men, the median age was 36.6 months (range, 5-93 months), and the tumor had an adrenal location in 23 (66%). All of the tumors were classified as stage IV. Metastasis to the bone marrow or bone was seen in 27 (71%). Thirty-three patients (94%) received autologous hematopoietic stem-cell transplantation (HSCT). The status prior to HSCT was complete remission in 19 (58%) and partial remission in 14 (42%). The treatment-related mortality rate was 15%, and the relapse rate was 68%. The median time to relapse was 15 months (3-52 months). The probability of overall survival and 5-year event-free survival was 37.8% ± 8.4 and 23.8% ± 7.3 (median follow-up of 40 months), respectively. Conclusion: Despite intensive treatment and adequate support measures, the prognosis for high-risk neuroblastoma in children remains poor in Uruguay. There is a need to incorporate new therapeutic strategies not yet available in our country.

Introducción:O neuroblastoma é o tumor sólido extracraniano mais frequente em crianças. Aproximadamente 50% dos pacientes são classificados como de alto risco considerando as características clínicas, biológicas e histológicas. Objetivo: Descrever a população atendida no Centro Hemato-Oncológíco Pediátrico (CHOP) do Centro Hospitalario Pereira Rossell (CHPR) com diagnóstico de neuroblastoma de alto risco, seu tratamento e sobrevida. Método: Estudo descritivo, retrospectivo, de todos os pacientes com neuroblastoma de alto risco diagnosticados no CHOP, no período entre 2001 e 2015. O Registro Nacional de Câncer Pediátrico está localizado no CHOP, bem como o Arquivo de Histórias Clínicas de todos os pacientes. Os dados são coletados e analisados pelo setor estatístico. Resultados: Foram diagnosticados 35 pacientes. Vinte (57%) eram do sexo masculino. Mediana de idade: 36,6 meses (5-93). Localização suprarrenal: 23 (66%). Estádio IV 100%. Metástases, medula óssea e osso: 27 (71%). Trinta e três pacientes receberam transplante de células-tronco hematopoiéticas (TCTH) (94%). Status prévio a TCTH, remissão completa: 19 (58%), remissão parcial: 14 (42%). Incidência de mortalidade relacionada ao tratamento: 15% e de recaídas: 68%. Mediana do tempo de recaída: 15 meses (3-52). A probabilidade de sobrevida global e sobrevida livre de eventos aos cinco anos foi de 37,8% ± 8,4 e 23,8% ± 7,3 (mediana de seguimento 40 meses). Conclusão: Apesar do tratamento intensivo e medidas de suporte adequadas, o prognóstico em crianças com neuroblastoma de alto continua sendo pobre no Uruguai. É necessário incorporar novas estratégias terapêuticas que ainda não estão disponíveis em nosso meio

Técnicas y medidas tendientes a disminuir el sangrado y el consumo de hemocomponentes en trasplante hepático. Evaluación de los primeros dos años de la Unidad Bi-Institucional de Trasplante Hepático en la especialidad Medicina Transfusional y Hemoterapia / Techniques and measures geared to reducing bleeding and the consumption of hemocomponents in liver transplant. Evaluation of the first two years at the Bi-Institutional Transplant Unit in the Transfusion Medicine and Hemotherapy specialization. Results of the participation of the Transfusion Medicine Department on the indicatio of deplasmatized bloodduring heart surgery preoperative period

Introducción: el trasplante hepático (TH) es el único tratamiento definitivo para la enfermedad hepática terminal crónica y patologías que no cuentan con otra alternativa terapéutica. El sangrado y el consumo de hemocomponentes se ha vinculado al descenso de la sobrevida del injerto y del paciente. Objetivo: evaluar los resultados en el consumo de hemocomponentes con la utilización de medidas y técnicas tendientes a minimizar el sangrado. Estimar la sobrevida. Material y método: se realiza un estudio descriptivo, observacional, retrospectivo de los primeros 31 pacientes sometidos a TH. Para la búsqueda de asociación entre variables de tipo cualitativo se utilizó test de chi cuadrado para un nivel de significación ?= 0,05, para el análisis de sobrevida fue utilizado Kaplan-Meyer. Resultados: se diseñó un score para analizar el consumo de hemocomponentes; en cinco pacientes (16,1%) no se transfundieron unidades de sangre desplasmatizada (u SD) y en 58,1% se consumieron de 1 a 4 u SD, con un promedio de 3,7 ± 0,6. Un solo paciente (3,2%) se trasplantó sin transfusión de hemocomponentes. A los seis meses la sobrevida corresponde a 81,3%, con un total de cinco eventos, permaneciendo vivos al final del estudio 26 pacientes. Conclusiones: las medidas para disminuir el sangrado y los requerimientos transfusionales fueron efectivos. Los resultados fueron aceptables, cercanos a los publicados a nivel internacional.

Abstract Introduction: liver transplant is the only final treatment for chronic terminal liver disease and other conditions that have no alternative therapies. Bleeding and the hemocomponents consumption has been associated to reduction of graft survival and patient. Objective: to evaluate results in hemocomponents consumption with the application of measures and techniques that aim to minimize bleeding. To estimate survival time. Method: descriptive, observational, retrospective study of the first 31 patients who had undergone liver transplant. A chi square test was used to find the qualitative variables association, significance level ? = 0.05, the Kaplan Meyer test was used to analyse survival. Results: a score was designed to analyse hemocomponent consumption, no deplasmatized blood units were transfused in 5 patients (16.1%), and 1 to 4 deplasmatized blood units were consumed in 58.1%, with a 3.7 ± 0.6 average. A single patient (3.2%) was transplanted with no hemocomponent transfusion. Upon six months, survival represents 81.3%, with a total of five events, 26 patients being alive towards the end of the study. Conclusions: measures to diminish bleeding and transfusion requirements were effective. Results were acceptable, similar to those published globally.

Resumo Introdução: o transplante hepático (TH) é o único tratamento definitivo para a doença hepática terminal crônica e outras patologias que não contam com alternativas terapêuticas. O sangramento e o consumo de hemocomponentes foram vinculados à diminuição da sobrevida do enxerto e do paciente. Objetivo: avaliar o consumo de hemocomponentes utilizando medidas e técnicas que buscam minimizar o sangramento. Estimar a sobrevida. Material e método: estudo descritivo, observacional, retrospectivo dos primeiros 31 pacientes submetidos à TH. Para buscar a associação entre variáveis de tipo qualitativo foi utilizado o teste do , com um nível de significância ? = 0,05; para a análise de sobrevida foi utilizado o teste de Kaplan Meyer. Resultados: foi elaborado um índice para analisar o consumo de hemocomponentes; cinco pacientes (16,1%) não receberam unidades de sangue desplasmatizada (u SD) e 58,1% consumiram de 1 a 4 u SD, com uma média de 3,7 ± 0,6. Somente um (3,2%) foi transplantado sem transfusão de hemocomponentes. A sobrevida aos seis meses foi de 81,3%, com um total de cinco eventos, permanecendo vivos ao final do estudo 26 pacientes. Conclusões: as medidas para diminuir o sangramento e os requerimentos transfusionais foram eletivas. Os resultados foram aceitáveis, próximos aos valores publicados a nível internacional.

Neuroblastoma en niños menores de 18 meses. Experiencia de 10 años en Centro Hematooncológico / Neuroblastoma less than 18 months of age. 10 years experience in pediatric hematooncologic of the Pereira Rossell Hospital Center

Introducción: el neuroblastoma es el tumor maligno más frecuente en los lactantes. Su curso clínico es variable, desde la regresión espontánea a la progresión maligna, y los factores pronósticos son múltiples, como edad, estadio, amplificación de N-myc y ploidía tumoral. Se describen las características de todos los pacientes con neuroblastoma menores de 18 meses asistidos en CHOP. Pacientes y métodos: estudio observacional, descriptivo y retrospectivo en el período entre 31 de enero de 2000 y 31 de enero de 2011. El diagnóstico se realizó por histología y aspirado de médula ósea. Los pacientes se estadificaron por INSS; el tratamiento se decidió según estadio y riesgo. Resultados: se incluyeron 22 pacientes menores de 18 meses (52% de todos los neuroblastomas), con una media de edad de 9,6 meses. Once pacientes se encontraban en estadio 4. La localización más frecuente fue suprarrenal; presentaban metástasis 13 pacientes. Quince niños recibieron poliquimioterapia y 20 fueron tratados quirúrgicamente. La amplificación del gen N-myc se demostró en tres pacientes. La sobrevida global fue de 77% y la sobrevida libre de enfermedad fue de 77%. Discusión y conclusiones: la mayor parte de los casos fueron diagnosticados en niños menores de 9 meses. Fueron más frecuentes los estadios 4 y 1. No se pudo demostrar asociación entre N-myc y estadio de enfermedad. La sobrevida fue excelente.

Introduction: neuroblastoma is the most common malignant tumor in infants. Its clinical behavior is variable, from spontaneous regression to malignant progression; prognostic factors are multiple, such as age, stage, N-myc amplification and tumor ploidy. We describe the characteristic of all patients with neuroblastoma less than 18 months of age assisted in CHOP. Patients and methods: retrospective, observational and descriptive study in the period between 31/1/00 y 31/01/11. Diagnose was made from histology and bone marrow aspirate. Patients were classified by INSS stage; treatment was decided according to stage and risk. Results: 22 patients were included (52% of all neuroblastomas), with a mean age of 9,6 months. Eleven patients were classified in stage 4. The most frequent localization was adrenal; 14 patients presented methastasis. Fifteen patients received chemotherapy and 20 were surgically intervened. N-myc amplification was detected in 3 patients. Overall survival was 77% and event-free survival was 77%. Discussion and conclusions: the majority of cases were diagnosed in children younger than 9 months. Stages 4 and 1 were the most frequent. No association between N-myc and stage could be determined. Overall and event-free survival were excellent.

[Evolution of the response to the first-line therapy for Helicobacter pylori infection in Uruguay]. / Evolución de la respuesta al tratamiento de primera línea de la infección por Helicobacter pylori en Uruguay.

INTRODUCTION: The eradication rate of the Helicobacter pylori (H pylori) infection using standard triple therapy has dropped globally in recent years, primarily due to the occurrence of antibiotic resistance. METHODS: Several therapy regimens were assessed in 823 patients treated the first time for H pylori infection in Uruguay, during the 1997 to 2011 period, divided into five-year groups. All patients underwent 13C isotope-urea breath testing, between the 8th and 24th weeks after therapy. The standard triple plan (amoxicillin, clarithromycin and proton pump inhibitors) was the most commonly used (86.8%). RESULTS: The overall eradication rate was 66.6% (548 patients). With the standard triple plan, the reported eradication rates were 75% for the first 5-year term and 70.1% for the second 5-year term. The difference between these two periods was not statistically significant (P = 0.201). However, in the last term the eradication rate further declined to 62.4%, with a statistically significant difference (P = 0.014). No significant correlations were found between the response to therapy in this population and either the use of alcohol and/or yerba mate or the smoking habits. CONCLUSIONS: In Uruguay, the eradication rate of H pylori infection has dropped in the last five years and is below the internationally accepted levels. This feature demands searching for more effective alternative therapies, adapting the management to the national reality based on local antibiotic resistance patterns and drug availability.

Trasplante alogénico haploidéntico de progenitores hematopoyéticos en pediatría en Uruguay / Haploidentical allogeneic hematopoietic transplant of hematopoietic parents in pediatrics in Uruguay

Introducción: el trasplante alogénico de progenitores hematopoyéticos (TPH) es actualmente la única opción de tratamiento curativo disponible para un número de neoplasias hematológicas de alto riesgo, así como para algunas enfermedades no malignas hereditarias o adquiridas. El TPH haploidéntico (HI) es una opción válida para pacientes que no tienen un hermano HLA-idéntico. Objetivo: describir los resultados obtenidos con TPH HI en pediatría. Material y método: en el año 2005 se inició en el Centro Hemato-Oncológico Pediátrico del Centro Hospitalario Pereira Rossell un programa de TPH HI para aquellos pacientes sin donante relacionado HLA-idéntico. Resultados: se trasplantaron 32 pacientes, 24 con neoplasias hematológicas y 8 con enfermedades no malignas. Se utilizaron dos estrategias de prevención de la enfermedad injerto contra huésped (EICH), depleción de linfocitos T (DLT) in vitro (28 pacientes) y DLT alorreactivos in vivo con altas dosis de ciclofosfamida postrasplante (4 pacientes). Veintisiete pacientes (84%) tuvieron un implante con quimerismo total del donante. La incidencia de EICH agudo y crónico fue de 26,9% y 11,8%, respectivamente. La muerte no relacionada a recaída al año del trasplante fue de 21,9%. Con una mediana de seguimiento de 32 meses, la sobrevida global a dos años fue de 52,4%. Conclusiones: el TPH HI ha demostrado ser una opción factible en nuestro medio para aquellos pacientes sin donante HLA-idéntico. Los resultados son comparables a los obtenidos con otros donantes alternativos y con costos más accesibles. Uruguay está hoy día mejor posicionado para ofrecer un TPH a los pacientes que así lo requieran...

Retraimiento sostenido: Un indicador de riesgo en el desarrollo temprano

Este estudio muestra los aportes de una herramienta para la vigilancia del desarrollo psicoemocional temprano, que puede ser incorporada a la práctica del pediatra en el primer nivel, favoreciendo una concepción integral del control de salud. Se realizó la detección temprana de indicadores de retraimiento durante la consulta pediátrica con la escala ADBB (Guedeney, 2001/2007) a 67 bebés entre 2 y 14 meses, filmados en cuatro visitas pediátricas durante el año 2010, en dos centros de salud pública. Se trabajó en dos líneas paralelas. Un pediatra con formación en ADBB desde el inicio del estudio realizó la consulta de 30 bebés, y en caso de detectar retraimiento realizó intervenciones orientadas a promover nuevos recursos en los padres en la relación temprana. Otros 37 bebés fueron atendidos en sus controles habituales por nueve pediatras, quienes fueron formados en ADBB y en la implementación de intervenciones, después de la segunda consulta videofilmada. Resultados: de los 37 bebés, 40% presentaban retraimiento en la primera evaluación, 57% en la segunda y después de la capacitación (tercera evaluación), el retraimiento bajó a 13%. En el grupo de 30 bebés, los porcentajes de retraimiento fueron: 7% en la primera evaluación, 13% en la segunda, 10% en la tercera, y 3% en la cuarta. Conclusión: una perspectiva interdisciplinaria que incluye el desarrollo emocional temprano y el uso de la escala ADBB en la consulta de control en salud, brinda mayores herramientas para realizar detecciones tempranas e intervenciones oportunas desde la atención primaria, ganando en calidad de atención.

This study shows the contributions of a tool for the alertness of the psycho-emotional emotional development that could be integrated in the pediatrician practice in the First Level, in order to promote a more integrated approach of infant´s health. Early detection of withdrawal indicators was done with ADBB scale (Guedeney, 2001/2007) during regular pediatric consultation to 67 babies between 2 and 14 months, who were video-taped in four pediatric visits during 2010 in two Public Health Centers. Two parallel ways were done. One pediatrician trained in ADBB since the beginning of the study assessed 30 babies and in the cases which she detected withdrawal, she did interventions oriented to promote in the parents new resources in the early relationship. The others 37 babies were assisted in their regular pediatric visits in the traditional way by nine pediatricians, who were trained in ADBB and in the implementation of interventions after the second video-taped consultation. Results: in the group of 37 infants, 40% presented withdrawal in the 1st. assessment, 57% in the 2nd, and in the 3rd one, which was done after the training, the percentage of withdrawal decrease to 13%. In the parallel group of 30 infants the percentages were: 7% in the 1st. assessment, 13% in the 2nd, 10% in the 3rd, and 3% in the 4th one. Conclusion: an interdisciplinary approach that includes the early emotional development and ADBB scale in the regular well-baby consultation offers new tools for early detection and for timely interventions from the first level of care, increasing the quality of the care.

Evolución de la respuesta al tratamiento de primera línea de la infección por Helicobacter pylori en Uruguay / [Evolution of the response to the first-line therapy for Helicobacter pylori infection in Uruguay].

INTRODUCTION: The eradication rate of the Helicobacter pylori (H pylori) infection using standard triple therapy has dropped globally in recent years, primarily due to the occurrence of antibiotic resistance. METHODS: Several therapy regimens were assessed in 823 patients treated the first time for H pylori infection in Uruguay, during the 1997 to 2011 period, divided into five-year groups. All patients underwent 13C isotope-urea breath testing, between the 8th and 24th weeks after therapy. The standard triple plan (amoxicillin, clarithromycin and proton pump inhibitors) was the most commonly used (86.8

(548 patients). With the standard triple plan, the reported eradication rates were 75

for the first 5-year term and 70.1

for the second 5-year term. The difference between these two periods was not statistically significant (P = 0.201). However, in the last term the eradication rate further declined to 62.4

, with a statistically significant difference (P = 0.014). No significant correlations were found between the response to therapy in this population and either the use of alcohol and/or yerba mate or the smoking habits. CONCLUSIONS: In Uruguay, the eradication rate of H pylori infection has dropped in the last five years and is below the internationally accepted levels. This feature demands searching for more effective alternative therapies, adapting the management to the national reality based on local antibiotic resistance patterns and drug availability.

Evolución de la respuesta al tratamiento de primera línea de la infección por Helicobacter pylori en Uruguay. / [Evolution of the response to the first-line therapy for Helicobacter pylori infection in Uruguay].

INTRODUCTION: The eradication rate of the Helicobacter pylori (H pylori) infection using standard triple therapy has dropped globally in recent years, primarily due to the occurrence of antibiotic resistance. METHODS: Several therapy regimens were assessed in 823 patients treated the first time for H pylori infection in Uruguay, during the 1997 to 2011 period, divided into five-year groups. All patients underwent 13C isotope-urea breath testing, between the 8th and 24th weeks after therapy. The standard triple plan (amoxicillin, clarithromycin and proton pump inhibitors) was the most commonly used (86.8

). RESULTS: The overall eradication rate was 66.6

(548 patients). With the standard triple plan, the reported eradication rates were 75

for the first 5-year term and 70.1

for the second 5-year term. The difference between these two periods was not statistically significant (P = 0.201). However, in the last term the eradication rate further declined to 62.4

, with a statistically significant difference (P = 0.014). No significant correlations were found between the response to therapy in this population and either the use of alcohol and/or yerba mate or the smoking habits. CONCLUSIONS: In Uruguay, the eradication rate of H pylori infection has dropped in the last five years and is below the internationally accepted levels. This feature demands searching for more effective alternative therapies, adapting the management to the national reality based on local antibiotic resistance patterns and drug availability.

Gastric endoscopic submucosal dissection: from animal model to patient.

AIM: To assess whether the use of porcine models is useful for learning endoscopic submucosal dissection (ESD), thus contributing to its subsequent application in human patients. METHODS: This study/learning process was carried out in 3 phases: Phase I: Ex vivo animal; Phase II: In vivo animal; Phase III: Humans. One endoscopist performed 30 gastric ESDs in porcine models, and later 5 gastric ESDs in 5 patients. The ESD was done following the method practiced at the National Cancer Center in Tokyo, Japan. Technical aspects, size, time and speed of ESD, as well as complications were registered. In patients, their clinical, endoscopic and histologic evolution was additionally added. RESULTS: Thirty en bloc ESDs were carried out in animal models. The mean ± SD size of the pieces was of 28.4 ± 1.2 mm, and the time of ESD was 41.7 ± 2.4 min. The time of ESD in the first 15 procedures was 43.0 ± 3.0 min whereas in the next 15 procedures, the time was 40.3 ± 3.9 min, P = 0.588. The speed in the first 15 ESDs was 1.25 ± 0.11 cm(2)/min vs 2.12 ± 0.36 cm(2)/min in the remaining 15, P = 0.028. There were no complications. In patients, 5 lesions were resected en bloc. The size of the pieces was 25.2 ± 5.1 mm and the time was 85.0 ± 25.6 min. Endoscopic and histological controls did not show evidence of residual neoplastic tissue. CONCLUSION: A sequential ESD training program of a unique endoscopist, based on the practice in porcine models, contributed to learning ESD for its subsequent application in humans, yielding good results in efficacy and safety.

Nivel de conocimiento de la enfermedad en una cohorte de pacientes con insuficiencia cardíaca / Level of disease awareness in a cohort of patients with heart failure

La causa más frecuente de reingresos por insuficiencia cardíaca es el mal cumplimiento terapéutico del paciente. Ello puede atribuirse a falta de conocimiento, a la complejidad del tratamiento, a deterioro cognitivo, a depresión o a una comunicación poco efectiva o inadecuada para el paciente por parte del equipo asistencial. Estudios previos muestran altos porcentajes de inadecuado conocimiento de la enfermedad en estos pacientes. En Uruguay no hay estudios que verifiquen esta situación. En el presente trabajo se analizó el conocimiento acerca de su enfermedad entre los pacientes controlados en una unidad especializada de insuficiencia cardíaca utilizando el método de encuesta mediante cuestionario autogestionado diseñado por los investigadores. Un elevado número de pacientes no conocen el diagnóstico de su enfermedad ni sus características, los factores de riesgo para enfermar y/o los factores de riesgo de descompensación. Esto debe obligar a otros análisis en cuanto a barreras de comunicación médico-paciente y/o a instrumentar planes educativos que puedan ser evaluados.

The most common cause of readmission for heart failure is poor patient compliance. This can be attributed to lack of knowledge, the complexity of treatment, cognitive impairment, depression or to an ineffective or inadequate communication to the patient by the healthcare team. Previous studies show a high percentage of inadequate knowledge about the disease in these patients. In Uruguay there are no studies that verify this. In this paper we analyzed the knowledge about their disease among the patients managed in a specialist heart failure unit using the survey method through self-administered questionnaire designed by the researchers.
A large number of patients do not know the diagnosis of the disease or the characteristics of the same, the risk factors for disease and / or risk factors of decompensation This should force other barriers analysis for doctor-patient communication and/or implement educational plans can be evaluated.

Prevalencia de depresión en la cohorte de pacientes de una unidad de insuficiencia cardíaca crónica / Prevalence of depression in a cohort of patients at a chronic heart failure unit

Objetivos: determinar la prevalencia de depresión en la cohorte de seguimiento de la UMIC y analizar la posible asociación de depresión con variables clínicas y paraclínicas Clase funcional NYHA (CFNYHA) y fracción de eyección del ventrículo izquierdo (FEVI). Material y método: estudio transversal, descriptivo, observacional, en 151 pacientes con IC. Criterios de inclusión: pertenecer a la cohorte de seguimiento UMIC (IC por disfunciónsistólica con FEVI menor a 40%), estar clínicamente estable y acceder, con consentimiento firmado, a la entrevista con el test aplicado. Criterios de exclusión: inestabilidad clínica porelementos de descompensación cardiovascular e imposibilidad cognitiva, neurológica o auditiva de realizar la entrevista. Se aplicó el test validado Patients Health Questionnaire 9 (PHQ9) y se definió como punto de corte un valor ≥15 para definir depresión con especificidad de 0,96. Resultados:se incluyeron 151 pacientes de cohorte de seguimiento UMIC. Según PHQ9 se observó que 29,8% (n=45)presentaba depresión mayor moderadamente severa o severa (PHQ9 ≥15). El promedio de edad de los pacientes con depresión (PCD) correspondió a 59,1±1,8 años (rango 20-80). En los pacientes sin depresión (PSD) correspondió a 61,5±1,2 años (rango 25-82). No existieron diferencias estadísticamente significativas entre PCD y PSD, según la edad. En cuanto a la asociación entre el sexo y la clase funcional, y la presencia o no de depresión, no se encontró asociación entre variables (p=0,287 y p=0,515). No se encontró diferencia estadísticamente significativa en laCFNYHA, según presencia o no de depresión (p=0,655), ni en la FEVI entre PCD y PSD (p=0,457).Conclusiones: la depresión es considerada hoy día una comorbilidad frecuente en la IC, llegando en la cohorte UMIC al 29,8% de esta. La presencia de depresión identifica a un grupo de pacientes con peor pronóstico.

Objectives: to determine the prevalence of depression in the cohort of patients under follow-up by the Multidisciplinary Unit of Heart Failure (UMIC) and toanalyse the potential association of depression with clinical and paraclinical variables: NYHA functional classification (CFNYHA) and left ventricular ejection fraction (LVEF). Method: transversal descriptive, observational study of 151 patients with HF. Inclusion criteria: belonging to the cohort of patients under follow-up by the Multidisciplinary Unit of Heart Failure (UMIC) (HF for systolic dysfunction with LVEF lower than 40%), being clinically stable and agreeing, by means of a written consent, to being interviewed and under going the test. Exclusion criteria: clinical instabilitydue to cardiovascular decompensation elements and cognitive, neurologic or hearing impairments that do not allow for the interview to be conducted.The test validated by Patients Health Questionnaire 9 (PHQ9) was applied, and the cut off was set in a value ≥15 to define depression, with a 0.96 of specificity. Results: 151 patients were included in the cohort of patients under follow-up by UMIC. The PHQ9 revealed that 29.8% (n=45) showed moderately severe or severe major depression (PHQ9 ≥15). Average age of patientswith depression was 59.1 ± 1.8 years (20-80 range) and patients with no depression 61.5 ± 1.2 years (25-82 range). There were no statistically significant differences between the groups with and without depression in terms of age. As to the association of depression and gender and functional classification with depression, no association among variables was found (p=0.287 y p=0.515). No statistically significant differences were found inthe NYHA functional classification according to the presence or absence of depression (p=0.655), neither in the association of LVEF with patients with or without depression (p=0.457).Conclusions: The presence of depression identifies a group of patients with a worse prognosis.

Objetivos: determinar a prevalência de depressão na coorte de seguimento da UMIC e analisar a possível associação de depressão com variáveis clínicas e de laboratório, classe funcional NYHA (CFNYHA) e fração de ejeção do ventrículo esquerdo (FEVE).Material e método: foi realizado um estudo transversal, descritivo, observacional, em 151 pacientes comIC. Critérios de inclusão: pertencer à coorte de seguimento UMIC (IC por disfunção sistólica com FEVE me-nor a 40%), estar clinicamente estável e aceitar, com consentimento assinado, à entrevista com aplicação do teste. Critérios de exclusão: instabilidade clínica por elementos de descompensação cardiovascular e impossibilidade cognitiva, neurológica ou auditiva de realizar a entrevista.Foi aplicado o teste validado Patients Health Questionnaire 9 (PHQ9); foi definido como ponto de corteum valor ≥ 15 para definir depressão com especificidade de 0,96.Resultados: foram incluídos 151 pacientes da coorte de seguimento UMIC. Foi observado, de acordo como PHQ9, que 29,8% (n=45) apresentava depressão maior moderadamente severa ou severa (PHQ9 ≥15). A idade média dos pacientes com depressão (PCD) foi59,1 ± 1,8 anos (intervalo 20-80) e 61,5 ± 1,2 anos (intervalo 25-82) entre os pacientes sem depressão (PSD).Não se encontraram diferenças estatisticamente significativas entre PCD e PSD, segundo idade.Com relação à associação entre sexo e classe funcional, e presença ou não de depressão, não foi encontrada associação entre variáveis (p=0,287 y p=0,515). Não foram encontradas diferenças estatisticamente significativas na CFNYHA, segundo presença ou não de depressão (p=0,655), nem na FEVE entre PCD e PSD (p=0,457).Conclusões: atualmente a depressão é considerada como uma comorbidade frequente na IC, alcançando na coorte UMIC 29,8%. A presença de depressão identifica a um grupo de pacientes com pior prognóstico.

Neuroblastoma en niños menores de 18 meses. Experiencia de 10 años en Centro Hematooncológico Pediátrico del Centro Hospitalario Pereira Rossel / Neuroblastome in children younger than 18 months. Ten years experience at the Pediatric Hemato Oncological Center of the Centro Hospitalario Pereira Rossell

El neuroblastoma es el tumor maligno más frecuente en los lactantes. Su curso clínico es variable, desde la regresión espontánea a la progresión maligna, y los factores pronósticos son múltiples, como edad, estadio, amplificación de N-myc y ploidía tumoral. Se describen las características de todos los pacientes con neuroblastoma menores de 18 meses asistidos en CHOP. Pacientes y métodos: estudio observacional, descriptivo y retrospectivo en el período entre 31 de enero de 2000 y 31 de enero de 2011. El diagnóstico se realizó por histología y aspirado de médula ósea. Los pacientes se estadificaron por INSS; el tratamiento se decidió según estadio y riesgo. Resultados: se incluyeron 22 pacientes menores de 18 meses (52% de todos los neuroblastomas), con una media de edad de 9,6 meses. Once pacientes se encontraban en estadio 4. La localización más frecuente fue suprarrenal; presentaban metástasis 13 pacientes. Quince niños recibieron poliquimioterapia y 20 fueron tratados quirúrgicamente. La amplificación del genN-myc se demostró en tres pacientes. La sobrevida global fue de 77% y la sobrevida libre de enfermedad fuede 77%. Discusión y conclusiones: la mayor parte de los casosfueron diagnosticados en niños menores de 9 meses. Fueron más frecuentes los estadios 4 y 1. No se pudo demostrar asociación entre N-myc y estadio de enfermedad. La sobrevida fue excelent...

Estudio caso-control de uso de complejo protrombínico en cirugía de switch arterial / Case-control study of use of complex protrombinico in surgery of arterial switch

Objetivo: El objetivo del siguiente trabajo fue evaluar si existió diferencia de reposición de hematocomponentes intra y postoperatoria, de sangrado y de reintervención en las primeras 24 horas, en pacientes intervenidos de switch arterial, según uso o no de complejo protombínico. Material y métodos: Se describieron las variables en estudio por grupo o para toda la población. Se utilizaron el test de Fischer y t de Student para comparar los grupos, con una significacion estadística alfa=0.05. Resultados: No hubo diferencias en cuento a sexo, edad, peso, tiempo de circulación extracorpórea, ni clampeo aórtico entre los dos grupos. La saturación al ingreso en los pacientes que se usó complejo fue menor que los del grupo control (p=0.044). Hubo mayor número de pacientes tratados con plasma intraoperatorio en los que no se administró complejo (p=0.046) y mayor volúmen de resposición con crioprecipitados también en el grupo sin complejo (p=0.02). Los pacientes que salieron con tórax abierto tuvieron mayor reposición de sangre desplasmatizada (p=0.041) y plaquetas (p=0.029) independientemente de su pertenencia al grupo con o sin complejo. No hubo diferencias con respecto al sangrado por los drenajes. Hubo solo un caso con reintervención por sangrado en el grupo control. Conclusiones: Hubo una tendencia de reposición mayor con plasma y crioprecipitados en el intraoperatorio en los pacientes que no se usó complejo protombínico, con significación estadística.

Incidence of inflammatory bowel disease in five geographical areas of Uruguay in the biennial 2007-2008.

INTRODUCTION: The incidence of inflammatory bowel disease (IBD) is different according to the geographical areas. No data on the incidence of IBD in Uruguay are available. OBJECTIVE: To determine the incidence of IBD, ulcerative colitis (UC) and Crohn's disease (CD), in five areas of Uruguay and to compare the results with those from other geographical regions. MATERIAL AND METHOD: A prospective study was performed in five areas of Uruguay during 2007-2008. The study population included 645,695 inhabitants. Multiple independent sources were used for the uptake of cases. Patients older than 14 years and living in the selected areas were included only after reviewing their medical history. Confirmed IBD was defined by a standard protocol after one year of follow up. RESULTS: A total of 34 cases were diagnosed in the study period, 29 UC and 5 CD. Crude incidence rate for IBD was 2.63 per 100,000 inhabitants/year, 2.25 and 0.39 for UC and CD, respectively. Adjusted rates were 4.26 per 100,000 inhabitants/year for UC and 0.74 per 100,000 inhabitants/year for CD. The UC/CD ratio was 5.8. The average age for IBD was 40.7 years. No statistically significant differences were found between UC and CD by age (P = 0.267) or gender (P = 0.489). CONCLUSIONS: Incidence rates of IBD place Uruguay in the regions of low incidence. As it has been described in low-incidence countries, UC is more common than CD. This study establishes a precedent to follow the evolution of IBD epidemiology in Uruguay.