Genetic variants of PON1, GSTM1, GSTT1, and locus 9p21.3, and the risk for premature coronary artery disease in Yucatan, Mexico.

OBJECTIVE: Genetic variants of PON1, rs70587, rs662, rs854560, GSTM1, and GSTT1 and two single nucleotide polymorphisms (SNP) at 9p21.3 locus, rs1333049, and rs2383207; were evaluated in association with the risk for premature coronary artery disease (CAD) in a population of Yucatan, Mexico. These genes are involved in the inactivation of pro-oxidants and pro-inflammatory mediators, lipid and xenobiotic metabolism, detoxification of reactive oxygen species, and regulation of cellular proliferation playing key roles in the pathogenesis of atherosclerosis. METHODS: We conducted a matched case-control study with 98 CAD cases and 101 healthy controls. Genotyping of PON1 and 9p21.2 SNP was performed by real time-PCR and for GSTM1 and GSTT1 with multiplex-PCR. Odds ratios (OR) were calculated to estimate association and generalized multifactor dimensionality reduction (GMDR) algorithm to identify gene-gene and gene-environment interactions. RESULTS: The distribution of all allele/genotype frequencies in controls was within Hardy-Weinberg expectations (p > .05) except for GSTM1. The allele/genotype frequencies of the GSTT1 null were significantly higher in CAD cases than in controls, suggesting association with higher risk for developing CAD. The other SNPs did not show any significant independent association with premature CAD. GMDR revealed a significant interaction between GSTT1 and LL55 genotype. Likewise, the body mass index (BMI) and smoking also showed an interaction with GSTT1. CONCLUSION: The GSTT1 null allele/genotype is associated with an increased risk of developing premature CAD, the effect of which is not modified by cardiovascular risk factors in the population of Yucatan.

Dysphagia lusoria in a young patient with a concomitant aortic arch anomaly, successfully treated with surgery: a case report.

Dysphagia is a common condition in clinical practice; however, an unusual type of dysphagia due to compression of the esophagus by an abnormal right subclavian artery may be discovered in a rare subset of patients. The prognosis and treatment will depend on the severity of the symptoms and the compromise of surrounding structures. We present the case of an 18-year-old female who presented with gradually progressive dysphagia. At first, it was treated as gastroesophageal reflux disease; nonetheless, the dysphagia became severe, and after a thorough evaluation, an aberrant right subclavian artery that compressed the esophagus was discovered along with a truncus bicaroticus. She was successfully treated with surgery without any complications. On follow-ups, she's doing well.

Epistasis analysis of metabolic genes polymorphisms associated with ischemic heart disease in Yucatan. / Análisis de epistasia de polimorfismos de genes metabólicos asociados a cardiopatía isquémica en Yucatán.

OBJECTIVE: Epistasis is a type of genetic interaction that could explain much of the phenotypic variability of complex diseases. In this work, the effect of epistasis of metabolic genes and cardiovascular risk on the susceptibility to the development of ischemic heart disease in Yucatan was determined. METHODS: Case-control study in 79 Yucatecan patients with ischemic heart disease and 101 healthy controls matched by age and origin with cases. The polymorphisms -108CT, Q192R, L55M (paraoxonase 1; PON1), C677T, A1298C (methylenetetrahydrofolate reductase; MTHFR), and the presence/absence of the glutathione S-transferase T1 (GSTT1) gene were genotyped. Epistasis analysis was performed using the multifactorial dimensional reduction method. The best risk prediction model was selected based on precision (%), statistical significance (P<0.05), and cross-validation consistency. RESULTS: We found an independent association of the null genotype GSTT1*0/0 (OR=3.39, CI: 1.29-8.87, P=0.017) and the null allele (OR=1.86, CI: 1.19-2.91, P=0.007) with ischemic heart disease. The GSTT1*0 deletion and the 677TT genotype (MTHFR) were identified as being at a high cardiovascular risk, whereas the GSTT1*1 wild type genotype and the CC677 variant were at low risk. The gene-environment interaction identified the GSTT1 gene, C677T polymorphism (MTHFR), and hypertension as the factors that best explain ischemic heart disease in the study population. CONCLUSIONS: The interaction of the MTHFR, GSTT1 and hypertension may constitute a predictive model of risk for early onset ischemic heart disease in the population of Yucatan.

Formación profesional del especialista en Medicina General Integral y su competencia para prevenir el suicidio / Professional training of the specialist in Comprehensive General Medicine and his competence to prevent suicide

Fundamento: una de las especialidades de posgrado que más ha impactado en el sistema nacional de salud es Medicina General Integral sustentada en el enfoque social de la medicina. Objetivo: determinar las tendencias históricas del proceso de formación profesional del especialista en Medicina General Integral y su influencia en el desarrollo de la competencia específica para prevenir el intento de suicidio. Métodos: se realizó una revisión bibliográfica sistemática para desarrollar un análisis crítico reflexivo del contenido de documentos, se consideraron tesis de doctorado, maestría, artículos originales y de revisión publicados entre 2005 y 2021 en español e inglés. La búsqueda fue realizada en las bases de datos SciELO y Google académico de enero 2021 a marzo de 2022. Desarrollo: a pesar del desarrollo alcanzado por la especialidad aún es insuficiente la preparación de ese capital humano como verdadero promotor de salud, porque no ha sido estructurado pensando en tales idoneidades y subyacen debilidades en su actuar preventivo donde la especialización de modos de actuación para prevenir el intento de suicidio como daño a la salud se ubica en vínculo indisoluble con la práctica asistencial de este galeno y necesita ser empoderado de conocimientos para elevar su competencia y desempeño exitoso. Conclusiones: el tratamiento de los indicadores en las etapas analizadas permite revelar las principales tendencias históricas del proceso de formación profesional del especialista en Medicina General Integral por lo que el desarrollo de una competencia preventivo-suicidológica emerge como una necesidad en su superación profesional.

Intoduction: one of the postgraduate specialties that has had the most impact on the national health system is Comprehensive General Medicine based on the social approach to medicine. Objective: to determine the historical trends of the professional training process of the Comprehensive General Medicine specialist and its influence on the development of the specific competence to prevent suicidal attempt. Methods: a systematic bibliographic review was carried out to develop a reflexive critical analysis of the content of documents, considering doctoral and master's theses, original and review articles published from 2005 to 2021 in Spanish and English. The search was carried out in the SciELO and academic Google databases from January 2021 to March 2022. Development: despite the development achieved by the specialty, the preparation of this human capital as a true health promoter is still insufficient, because it has not been structured with such qualifications in mind and there are underlying weaknesses in its preventive action where the specialization of modes of action to prevent The suicidal attempt as damage to health is inextricably linked with the care practice of this doctor and needs to be empowered with knowledge to increase his competence and successful performance. Conclusions: the treatment of the indicators in the stages analyzed allows revealing the main historical trends of the professional training process of the specialist in Comprehensive General Medicine, so the development of a preventive-suicidal competence emerges as a necessity in their professional improvement.

Usefulness of Drug-Eluting Balloons for Bare-Metal and Drug-Eluting In-Stent Restenosis (from the RIBS IV and V Randomized Trials).

Treatment of patients with drug-eluting stent (DES) in-stent restenosis (ISR) is particularly challenging. We sought to compare results of drug-eluting balloons in patients with DES-ISR with those in patients with bare-metal stent (BMS) ISR. A pooled analysis of the Restenosis Intra-Stent: Drug-Eluting Balloon versus Everolimus-Eluting Stent IV and V randomized trials was performed. Both trials had identical inclusion and exclusion criteria. Results of drug-eluting balloons in 95 patients with BMS-ISR and 154 patients with DES-ISR were compared. Patients with DES-ISR were more frequently diabetics, presented more often as an acute coronary syndrome and had more severe lesions and more frequently a focal pattern, including edge-ISR. Late angiographic findings (92% of eligible patients), including minimal lumen diameter (1.80 ± 0.6 vs 2.01 ± 0.6 mm, p = 0.001; absolute mean difference 0.21 mm; 95% confidence interval 0.04 to 0.38; p = 0.014) and restenosis rate (19% vs 9.5%, p <0.05) were poorer in DES-ISR. Results were consistent across 10 prespecified subgroups. Moreover, on multiple linear regression analysis, minimal lumen diameter at follow-up remained significantly smaller in patients with DES-ISR after adjusting for potential confounders (adjusted absolute mean difference 0.17 mm; 95% confidence interval 0.04 to 0.41; p = 0.019). Finally, at 1-year clinical follow-up (100% of patients), rates of target vessel revascularization (16% vs 6%, p = 0.02) and of the main combined clinical end point (18% vs 8%, p = 0.03) were significantly higher in patients treated for DES-ISR. In conclusion, this study confirms the efficacy of DEB for patients with ISR. However, the long-term clinical and angiographic results of DEB are poorer in patients with DES-ISR than in those with BMS-ISR. (ClinicalTrials.govIdentifier:NCT01239953&NCT01239940).

Un acercamiento al conocimiento de la presencia de marcadores neurobiológicos en la génesis del suicidio / An approach to the knowledge of the presence of neurobiological markers in the genesis of suicide / Uma abordagem para o conhecimento da presença de marcadores neurobiológicos nagênese do suicídio

RESUMEN El suicidio ha constituido desde siempre uno de los grandes enigmas de la humanidad. El presente trabajo tiene como objetivo abordar los elementos más actuales de la génesis neurobiológica de la conducta suicida que puedan contribuir a su prevención. Se realizaron diversas búsquedas en materiales impresos y digitales a partir de las consultas del catálogo online de la biblioteca virtual de Infomed, en bases de datos multidisciplinarias así como las revistas digitales certificadas. Entre los marcadores neurobiológicos descritos en la actualidad más destacados están bajos niveles del 5-HIAA en el líquido cefalorraquídeo (LCR), aumento de la densidad de los receptores 5-HT1A en la corteza pre- frontal, disminución de los sitios de unión del receptor serotoninérgico en la misma región, modificación del sistema GABA-érgico y los receptores benzodiazepínicos entre otros. A modo de conclusión se puede decir que los marcadores neurobiológicos y los factores psicopatológicos- de interacción familiar- de stress psicosocial descritos buscan identificar aquellos individuos con potencial riesgo de suicidio para establecer medidas de prevención, lo cual exige su detección e intervención a tiempo buscando evitar la ocurrencia del primer intento y a su vez la repetición del acto que conlleve al desenlace fatal.

ABSTRACT Suicide has always been one of the great enigmas of humanity. The present work aims to address the most current elements of the neurobiological genesis of suicidal behavior that can contribute to its prevention. Various searches were made of printed and digital materials based on queries in the online catalog of the Infomed virtual library, in multidisciplinary databases as well as certified digital journals. Among the most prominent neurobiological markers currently described are low levels of 5-HIAA in cerebrospinal fluid (CSF), increased density of 5-HT1A receptors in the prefrontal cortex, decreased receptor binding sites serotonergic in the same region, decrease in platelet serotonin receptors, modification of the GABA-ergic system and benzodiazepine receptors, among others. Suicide has multidimensional qualities and a multifactorial etiopathogenesis, therefore, in the consummation of the suicidal act, genetic factors -neurobiological - psychopathological - family interaction - psychosocial stress should be considered. By way of conclusion, the neurobiological and psychosocial markers described seek to identify those individuals with a potential risk of suicide to establish a prevention measure, which requires their detection and intervention in time, seeking to avoid the occurrence of the first attempt and, in turn, the repetition of the act that entails to the fatal outcome.

RESUMO O suicídios em prefoium dos grandes enigmas da humanidade. O presente trabalho visa abordar os elementos maisatuais da gênese neurobiológica do comportamento suicida que podem contribuir para sua prevenção. Foram realizadas várias pesquisas em materiais impressos e digitais do catálogo online da biblioteca virtual Infomed, em bases de dados multidisciplinares e também em revistas digitais certificadas. Entre os marcadores neurobiológicos mais proeminentes atualmente descritos estão baixos níveis de 5-HIAA no líquido cefalorraquidiano (LCR), aumento da densidade de receptores 5-HT1A no córtex pré-frontal, diminuição dos sítios de ligação do receptor serotonérgicona mesma região, modificação do GABA- sistema ergico e receptores de benzodiazepina, entre outros. A título de conclusão, pode-se dizer que os marcadores neurobiológicos e fatores psicopatológicos - de interação familiar - do estresse psicossocial descritos buscam identificar aqueles indivíduos com potencial risco de suicídio para estabelecer medidas de prevenção, o que requer sua detecção e intervenção em tempo, visando evitar a ocorrência da primeira tentativa e, por sua vez, a repetição do ato que leva ao resultado fatal.

Satisfacción estudiantil sobre el manual "Prevención de la Conducta Suicida" en Medicina General Integral / Student satisfaction with the manual "Prevention of Suicidal Behavior" in Comprehensive General Medicine

RESUMEN Fundamento: crear manuales que complementen y faciliten el aprendizaje del estudiante permite cumplir con el encargo social de los docentes como formadores de los futuros profesionales de la salud. Objetivo: valorar el nivel de satisfacción de los estudiantes de Medicina sobre el manual digital "Prevención de la Conducta Suicida" como recurso bibliográfico para facilitar el aprendizaje del referido tema en la disciplina integradora Medicina General Integral. Métodos: se realizó un estudio observacional descriptivo en en la Facultad de Ciencias Médicas de Manzanillo, Granma, en el curso 2018-2019. Se utilizaron métodos teóricos: análisis-síntesis, hipotético-deductivo y hermenéutico-dialéctico; empíricos: cuestionario a estudiantes como usuarios del manual, y para procesar la información se utilizó la estadística descriptiva. Resultados: el uso del manual facilitó la comprensión del contenido teórico y el desarrollo de habilidades para detectar riesgos en pacientes con este tipo de conducta, desde la educación en el trabajo en el consultorio médico de familia y otros escenarios docentes por donde los alumnos cumplen su rotación. Conclusiones: los estudiantes expresaron un nivel adecuado de satisfacción en sus respuestas sobre el uso del manual diseñado para los temas de la disciplina Medicina General Integral.

ABSTRACT Background: creating manuals that complement and facilitate student learning allows fulfilling the social mission of teachers as trainers of future health professionals. Objective: to assess the level of satisfaction of medical students on the electronic manual "Prevention of Suicidal Behavior" as a bibliographic resource to facilitate learning of the aforementioned subject in the integrative discipline General Comprehensive Medicine. Methods: a descriptive observational study was carried out in the Faculty of Medical Sciences of Manzanillo, Granma, in the 2018-2019 academic year. Theoretical methods were used: analysis-synthesis, hypothetical-deductive and hermeneutical-dialectical; empirical: questionnaire to students as users of the manual and descriptive statistics were used to process the information. Results: the use of the manual facilitated the understanding of the theoretical content and the development of skills to detect risks in patients with this type of behavior, from the in-service training in the GP's office and other teaching institutions where students fulfill their rotation. Conclusions: the students expressed an adequate level of satisfaction in their answers about the use of the manual designed for the subjects of the comprehensive General Medicine discipline.

Long-Term Results of Everolimus-Eluting Stents Versus Drug-Eluting Balloons in Patients With Bare-Metal In-Stent Restenosis: 3-Year Follow-Up of the RIBS V Clinical Trial.

OBJECTIVES: The aim of this study was to compare the long-term efficacy of everolimus-eluting stents (EES) and drug-eluting balloons (DEB) in patients with bare-metal stent in-stent restenosis (ISR). BACKGROUND: The relative long-term clinical efficacy of current therapeutic modalities in patients with ISR remains unknown. METHODS: The 3-year clinical follow-up (pre-specified endpoint) of patients included in the RIBS V (Restenosis Intra-Stent of Bare-Metal Stents: Drug-Eluting Balloon vs Everolimus-Eluting Stent Implantation) randomized clinical trial was analyzed. All patients were followed yearly using a pre-defined structured questionnaire. RESULTS: A total of 189 patients with bare-metal stent ISR were allocated to either EES (n = 94) or DEB (n = 95). Clinical follow-up at 1, 2, and 3 years was obtained in all patients (100%). Compared with patients treated with DEB, those treated with EES obtained better angiographic results, including larger minimal luminal diameter at follow-up (primary study endpoint; 2.36 ± 0.6 mm vs. 2.01 ± 0.6 mm; p < 0.001). At 3 years, the rates of cardiac death (2% vs. 1%), myocardial infarction (4% vs. 5%) and target vessel revascularization (9% vs. 5%) were similar in the DEB and EES arms. Importantly, however, at 3 years, the rate of target lesion revascularization was significantly lower in the EES arm (2% vs. 8%; p = 0.04; hazard ratio: 0.23; 95% confidence interval: 0.06 to 0.93). The need for "late" (>1 year) target vessel (3 [3.2%] vs. 3 [3.2%]; p = 0.95) and target lesion (1 [1%] vs. 2 [2.1%]; p = 0.54) revascularization was low and similar in the 2 arms. Rates of definite or probable stent thrombosis (1% vs. 0%) were also similar in the 2 arms. CONCLUSIONS: The 3-year clinical follow-up of the RIBS V clinical trial confirms the sustained safety and efficacy of EES and DEB in patients treated for bare-metal stent ISR. In this setting, EES reduce the need for target lesion revascularization at very long-term follow-up. (RIBS V [Restenosis Intra-Stent of Bare Metal Stents: Paclitaxel-Eluting Balloon vs Everolimus-Eluting Stent] [RIBS V]; NCT01239953).

Comparison of the Efficacy of Everolimus-Eluting Stents Versus Drug-Eluting Balloons in Patients With In-Stent Restenosis (from the RIBS IV and V Randomized Clinical Trials).

Treatment of patients with in-stent restenosis (ISR) remains a challenge. This study sought to compare the efficacy of everolimus-eluting stents (EESs) and drug-eluting balloons (DEBs) with paclitaxel in patients with ISR. A pooled analysis of the Restenosis Intra-Stent of Drug-Eluting Stents: Drug-Eluting Balloon vs Everolimus-Eluting Stent (RIBS IV) and Restenosis Intra-Stent of Bare-Metal Stents: Drug-Eluting Balloon vs Everolimus-Eluting Stent (RIBS V) randomized trials was performed using patient-level data. In both trials, EESs were compared with DEBs in patients with ISR (RIBS V included 189 patients with bare-metal ISR; RIBS IV included 309 patients with drug-eluting ISR). Inclusion and exclusion criteria were identical in both trials. A total of 249 patients were allocated to EES and 249 to DEB. Clinical follow-up at 1 year was obtained in all (100%) patients and late angiography (median 249 days) in 91% of eligible patients. Compared with patients treated with DEBs, patients treated with EESs obtained better short-term results (postprocedural minimal lumen diameter 2.28 ± 0.5 vs 2.12 ± 0.4 mm, p <0.0001). At follow-up, patients treated with EESs had larger in-segment minimal lumen diameter (primary end point 2.16 ± 0.7 vs 1.88 ± 0.6 mm, p <0.0001; absolute mean difference 0.28 mm; 95% confidence interval [CI] 0.16 to 0.40) and net lumen gain (1.33 ± 0.6 vs 1.00 ± 0.7 mm, p <0.0001) and had lower %diameter stenosis (19 ± 21% vs 28 ± 22%, p <0.0001) and binary restenosis rate (8.7% vs 15.7%, p = 0.02). Consistent results were observed in the in-lesion analysis. No interactions were found between the underlying stent type and treatment effects. At 1-year clinical follow-up, the composite of cardiac death, myocardial infarction, and target vessel revascularization was significantly reduced in the EES arm (8.8% vs 14.5%, p = 0.03; hazard ratio 0.59, 95% CI 0.31 to 0.94) mainly driven by a lower need for target vessel revascularization (6% vs 12.4%, p = 0.01, hazard ratio 0.46, 95% CI 0.25 to 0.86). This pooled analysis of the RIBS IV and RIBS V randomized trials demonstrates the superiority of EES over DEB in the treatment of patients with ISR.

Everolimus-Eluting Stents in Patients With Bare-Metal and Drug-Eluting In-Stent Restenosis: Results From a Patient-Level Pooled Analysis of the RIBS IV and V Trials.

BACKGROUND: Treatment of patients with drug-eluting stent (DES) in-stent restenosis (ISR) is more challenging than that of patients with bare-metal stent ISR. However, the results of everolimus-eluting stents (EES) in these distinct scenarios remain unsettled. METHODS AND RESULTS: A pooled analysis of the RIBS IV (Restenosis Intra-Stent of Drug-Eluting Stents: Paclitaxel-Eluting Balloon vs Everolimus-Eluting Stent) and RIBS V (Restenosis Intra-Stent of Bare Metal Stents: Paclitaxel-Eluting Balloon vs Everolimus-Eluting Stent) randomized trials was performed using patient-level data to compare the efficacy of EES in bare-metal stent ISR and DES-ISR. Inclusion and exclusion criteria were identical in both trials. Results of 94 patients treated with EES for bare-metal stent ISR were compared with those of 155 patients treated with EES for DES-ISR. Baseline characteristics were more adverse in patients with DES-ISR, although they presented later and more frequently with a focal pattern. After intervention, minimal lumen diameter (2.22±0.5 versus 2.38±0.5 mm, P=0.01) was smaller in the DES-ISR group. Late angiographic findings (89.3% of eligible patients), including minimal lumen diameter (2.03±0.7 versus 2.36±0.6 mm, P<0.001) and diameter stenosis (23±22 versus 13±17%, P<0.001) were poorer in patients with DES-ISR. Results were consistent in the in-segment and in-lesion analyses. On multiple linear regression analysis, minimal lumen diameter at follow-up remained significantly smaller in patients with DES-ISR. Finally, at 1-year clinical follow-up (100% of patients), mortality (2.6 versus 0%, P<0.01) and need for target vessel revascularization (8 versus 2%, P=0.03) were higher in the DES-ISR group. CONCLUSIONS: This patient-level pooled analysis of the RIBS IV and RIBS V randomized clinical trials suggests that EES provide favorable outcomes in patients with ISR. However, the results of EES are less satisfactory in patients with DES-ISR than in those with bare-metal stent ISR. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifiers: NCT01239953 and NCT01239940.

Competencia y desempeño del médico de la familia en la prevención de la conducta suicida a nivel comunitario / Competence and performance of the family doctor in the prevention of suicidal behavior at the community level / Competência e atuação do médico de família na prevenção do comportamento suicida na comunidade

RESUMEN La investigación tiene como objetivo evaluar la competencia profesional y el desempeño del médico de familia en la prevención y control de la conducta suicida. Se realizó un estudio descriptivo, el universo fueron33médicos (residentes y especialistas) distribuidos en las 18 áreas de salud del Policlínico No.2 de Manzanillo. La información se obtuvo de una encuesta que permitió determinar el nivel de competencia específica para la prevención del intento y/o suicidio, una guía para evaluar el desempeño profesional y una entrevista focalizada buscando la triangulación metodológica. La mayoría de los médicos obtienen una competencia inadecuada 81.8%, la razón expresa que por cada 6 médicos evaluados con una competencia inadecuada hay solo 1 con una competencia adecuada, el 75.8%fueron evaluados con un desempeño profesional inadecuado, la razón expresa que por cada 5 médicos evaluados con un desempeño inadecuado hay solo 1 con un desempeño adecuado. Con la aplicación de los instrumentos validados se comprobó insuficientes conocimientos en los médicos de familia para el manejo de este daño a la salud a nivel comunitario lo que limita su actuación en la práctica asistencial y denota la necesidad de la superación postgraduada para resolver las insuficiencias detectadas.

ABSTRACT The research aims to evaluate the professional competence and performance of the family doctor in the prevention and control of suicidal behavior. A descriptive study was carried out, the universe was 33 doctors (residents and specialists) distributed in the 18 health areas of the Polyclinic No.2 of Manzanillo. The information was obtained from a survey that made it possible to determine the level of specific competence for the prevention of attempt and / or suicide, a guide to evaluate professional performance and a focused interview seeking methodological triangulation. Most of the doctors obtain an inadequate competence 81.8%, the reason expresses that for every 6 doctors evaluated with an inadequate competence there is only 1 with an adequate competence, 75.8% were evaluated with an inadequate professional performance, the reason expresses that for each 5 doctors evaluated with an inadequate performance there is only 1 with an adequate performance. With the application of the validated instruments, insufficient knowledge was found in family physicians for the management of this damage to health at the community level, which limits their performance in healthcare practice and denotes the need for postgraduate improvement to resolve the deficiencies detected.

RESUMO A pesquisa tem como objetivo avaliar a competência profissional e a atuação do médico de família na prevenção e controle do comportamento suicida. Foi realizado um estudo descritivo, o universo foi de 33 médicos (residentes e especialistas) distribuídos nas 18 áreas de saúde da Policlínica nº 2 de Manzanillo. As informações foram obtidas por meio de questionário que possibilitou determinar o nível de competência específica para a prevenção de tentativa e / ou suicídio, guia de avaliação do desempenho profissional e entrevista focada buscando triangulação metodológica. A maioria dos médicos obtém uma competência inadequada 81,8%, o motivo expressa que para cada 6 médicos avaliados com competência inadequada há apenas 1 com competência adequada, 75,8% foram avaliados com desempenho profissional inadequado, o motivo expressa que para cada 5 médicos avaliados com desempenho inadequado restando apenas 1 com desempenho adequado. Com a aplicação dos instrumentos validados, foi constatado conhecimento insuficiente dos médicos de família para o manejo desses agravos à saúde na comunidade, o que limita sua atuação na prática assistencial e denota a necessidade de aprimoramento da pós-graduação para sanar as deficiências detectadas.

Mechanisms of balloon angioplasty and repeat stenting in patients with drug-eluting in-stent restenosis.

BACKGROUND: Mechanisms of lumen gain during reinterventions in patients with drug-eluting stent (DES) in-stent restenosis (ISR) remain unsettled. METHODS: We sought to assess the mechanisms of acute lumen gain after balloon angioplasty (BA) and repeat drug-eluting stent (DES) implantation in patients with DES-ISR. Following a prospective protocol 29 consecutive patients with DES-ISR were sequentially treated with BA and new DES implantation under a multimodality intracoronary imaging assessment including intravascular ultrasound (IVUS) and optical coherence tomography (OCT). Imaging studies were systematically obtained, at baseline, after BA, and after DES. Results of interventions were compared using volumetric and morphometric (ISR pattern and injury score) analyses. RESULTS: IVUS and OCT demonstrated that acute lumen gain after BA and DES equally results from a reduction in intra-stent neointimal volume and further DES expansion. As compared with BA, repeat DES implantation not only increased final lumen (baseline 39.6±18.5mm(3), post-BA 58.6±26.6mm(3), post-DES 84.2±30.8mm(3), all p<0.001) but also provided a smoother lumen (injury score 1.57±0.86 vs 0.22±0.26, p<0.001). At the 9th month of angiographic follow-up (86% patients) in-stent late loss was 0.44±0.5mm and 4 patients (16%) developed ISR. The ISR pattern on OCT was not associated with the injury score after interventions or late angiographic findings. Likewise, the injury score did not predict late angiographic outcome. CONCLUSIONS: In patients with DES ISR, lumen gain equally results from a reduction in intra-stent neointimal volume and further DES expansion. As compared with BA, repeat DES implantation provides a larger and smoother coronary lumen.

Rationale and design of the RIBS IV randomised clinical trial (drug-eluting balloons versus everolimus-eluting stents for patients with drug-eluting stent restenosis).

AIMS: This study will compare the efficacy of drug-eluting balloons (DEB) and everolimus-eluting stents (EES) in patients with drug-eluting stent (DES) in-stent restenosis (ISR). METHODS AND RESULTS: This is a prospective, multicentre, randomised clinical trial comparing DEB and EES in patients with DES-ISR. The study is an investigator-driven initiative generated within the RIBS study programme. A total of 310 patients with DES-ISR will be included and randomised (1:1) to DEB or EES. Angiographic follow-up has been scheduled at six to nine months. Quantitative coronary analyses will be performed in a centralised core lab by blinded personnel. The primary endpoint of the study is minimal lumen diameter at angiographic follow-up. Other secondary angiographic endpoints include % diameter stenosis, late loss, net gain and binary restenosis rate. An independent clinical events committee will adjudicate clinical events after reviewing source documents. The main clinical outcome measure is a combined endpoint of cardiac death, myocardial infarction and target vessel revascularisation at one year. Individual components of the combined clinical endpoint and rates of target lesion revascularisation and stent thrombosis will also be compared. CONCLUSIONS: This randomised clinical trial will determine the relative efficacy of EES versus DEB in patients presenting with DES-ISR. (ClinicalTrials.gov Identifier: NCT01239940).

[G894T (NOS3) and G1958A (MTHFD1) gene polymorphisms and risk of ischemic heart disease in Yucatan, Mexico]. / Polimorfismos G894T del gen NOS3 y G1958A del gen MTHFD1 y riesgo de cardiopatía isquémica en Yucatán, México.

INTRODUCTION AND OBJECTIVES: Cardiovascular medicine is focused on the search for genetic risk markers with predictive and/or prognostic value. Among the genetic variants of interest are G894T endothelial nitric oxide synthase and G1958A methylenetetrahydrofolate dehydrogenase1 gene polymorphisms. The aim of this study was to determine the possible association between these polymorphisms and ischemic heart disease in patients from Southern of Mexico (Yucatán). METHODS: Case-control study matched by age, sex and origin was designed. We studied 98 patients with coronary disease and 101 controls. Participants were evaluated for the usual risk factors. The polymorphisms were identified using the polymerase chain reaction/restriction fragment length polymorphism analysis. Informed consent was obtained from all participants. RESULTS: The G894T and G1958A polymorphisms were not associated with ischemic heart disease, however, the TT genotype (G894T) was associated with the angina (OR=10.2; 95%CI, 1.51-68.8; p=0.025). The genotype GT (G894T) was the most frequent in patients with family history of coronary artery disease. Multiple logistic regression analysis identified smoking (OR=5.21; 95%CI, 2.1-12.9; p=0.000), hypertension (OR=3.54; 95%CI, 1.47-8.56; p=0.005) and obesity (OR=1.16; 95%CI, 1.1-1.27; p=0.001) as risk factors predicting the ischemic heart disease. CONCLUSIONS: The G894T and G1958A polymorphisms showed not association with ischemic heart disease. However, homozygosis for the 894T allele (NOS3) confers at risk to develop angina on Yucatán.

Conocimientos sobre la COVID 19 en pacientes del CMF No. 12 y acciones preventivas del trío de pesquisa / Knowledge about COVID 19 in CMF No. 12 patients and preventive actions of the research trio / Conhecimento sobre COVID 19 em pacientes com CMF nº 12 e ações preventivas do trio de pesquisa

RESUMEN Introducción: los grandes asesinos de la historia son las bacterias y los virus, a mediados de diciembre la humanidad comenzó a ser azotada por un nuevo virus SARS-CoV-2, originando una enfermedad llamada COVID 19. Objetivo: evaluar el nivel de conocimientos y el cumplimiento de las medidas preventivas sobre la COVID-19 en los pacientes antes y después de tener la presencia en el área de salud de un caso positivo a la Covid-19. Método: se realizó un estudio descriptivo con fase de intervención a los pacientes de tres Manzanas del consultorio # 12 del policlínico Ángel Ortiz Vázquez del municipio Manzanillo, de la provincia Granma. Resultados: los resultados obtenidos fueron de 583 pacientes un 55,5 por ciento presentan factores de riesgo, antes de la intervención un 34,8% desconocen vías de trasmisión, además un 44.0 % usan el nasobuco de forma inadecuado, lo cual aumento después de la pesquisa fortalecida aumento a un 97.7%, al igual que el nivel de conocimientos que aumento a un 91.0% y satisfacción de la comunidad con las acciones educativas a un 100%. Conclusiones: se observó después de las acciones educativas un aumento en el conocimiento de la enfermedad empoderando a la población de conocimientos y prácticas necesarias, los pacientes cumplieron adecuadamente las medidas preventivas y la satisfacción de la comunidad con el trabajo de los tríos participantes fue favorable.

ABSTRACT Introduction: the greatest killers in history are bacteria and viruses, in mid-December humanity began to be hit by a new SARS-CoV-2 virus, causing a disease called COVID 19. Objective: to assess the level of knowledge and compliance with preventive measures on COVID-19 in patients before and after having the presence in the health area of ​​a positive case for Covid-19. Method: a descriptive study with intervention phase was carried out on the patients of three apples from office # 12 of the Ángel Ortiz Vázquez polyclinic in the Manzanillo municipality, Granma province. Results: the results obtained were from 583 patients, 55.5 percent presented risk factors, before the intervention 34.8% were unaware of transmission routes, and 44.0% used the nasobuco improperly, which increased after the strengthened research increased to 97.7%, as did the level of knowledge that increased to 91.0% and satisfaction of the community with the educational actions to 100%. Conclusions: after the educational actions, an increase in the knowledge of the disease was observed, empowering the population with the necessary knowledge and practices, the patients adequately complied with the preventive measures and the satisfaction of the community with the work of the participating trios was favorable.

RESUMO Introdução: os maiores assassinos da história são bactérias e vírus. Em meados de dezembro, a humanidade começou a ser atingida por um novo vírus SARS-CoV-2, causando uma doença chamada COVID 19. Objetivo: avaliar o nível de conhecimento e a adesão às medidas preventivas do COVID-19 em pacientes antes e depois da presença na área da saúde de um caso positivo para o Covid-19. Método: foi realizado um estudo descritivo com uma fase de intervenção em pacientes de três maçãs do consultório nº 12 da policlínica Ángel Ortiz Vázquez no município de Manzanillo, província de Granma. Resultados: os resultados obtidos foram de 583 pacientes, 55,5 por cento apresentavam fatores de risco, antes da intervenção 34,8% desconheciam as vias de transmissão e 44,0% usavam indevidamente o nasobuco, que aumentava após a pesquisa reforçada aumentou para 97,7%, assim como o nível de conhecimento que aumentou para 91,0% e a satisfação da comunidade com as ações educativas para 100%. Conclusões: após as ações educativas, observou-se um aumento no conhecimento da doença, capacitando a população com os conhecimentos e práticas necessários, os pacientes cumpriram adequadamente as medidas preventivas e a satisfação da comunidade com o trabalho dos trios participantes foi favorável.

A Prospective Randomized Trial of Drug-Eluting Balloons Versus Everolimus-Eluting Stents in Patients With In-Stent Restenosis of Drug-Eluting Stents: The RIBS IV Randomized Clinical Trial.

BACKGROUND: Treatment of patients with drug-eluting stent (DES) in-stent restenosis (ISR) remains a major challenge. OBJECTIVES: This study evaluated the comparative efficacy of drug-eluting balloons (DEB) and everolimus-eluting stents (EES) in patients presenting with DES-ISR. METHODS: The study design of this multicenter randomized clinical trial assumed superiority of EES for the primary endpoint, in-segment minimal lumen diameter at the 6- to 9-month angiographic follow-up. RESULTS: A total of 309 patients with DES-ISR from 23 Spanish university hospitals were randomly allocated to DEB (n = 154) or EES (n = 155). At late angiography (median 247 days; 90% of eligible patients), patients in the EES arm had a significantly larger minimal lumen diameter (2.03 ± 0.7 mm vs. 1.80 ± 0.6 mm; p < 0.01) (absolute mean difference: 0.23 mm; 95% CI: 0.07 to 0.38) [corrected], net lumen gain (1.28 ± 0.7 mm vs. 1.01 ± 0.7 mm; p < 0.01), and lower percent diameter stenosis (23 ± 22% vs. 30 ± 22%; p < 0.01) and binary restenosis rate (11% vs. 19%; p = 0.06), compared with patients in the DEB arm. Consistent results were observed in the in-lesion analysis. At the 1-year clinical follow-up (100% of patients), the main clinical outcome measure (composite of cardiac death, myocardial infarction, and target vessel revascularization) was significantly reduced in the EES arm (10% vs. 18%; p = 0.04; hazard ratio: 0.58; 95% CI: 0.35 to 0.98), mainly driven by a lower need for target vessel revascularization (8% vs. 16%; p = 0.035). CONCLUSIONS: In patients with DES-ISR, EES provided superior long-term clinical and angiographic results compared with DEB. (Restenosis Intra-Stent of Drug-Eluting Stents: Drug-Eluting Balloon vs Everolimus-Eluting Stent [RIBS IV]; NCT01239940).

Enalaprilat improves systemic cardiovascular parameters and mesenteric blood flow during hypotensive resuscitation from hemorrhagic shock in dogs.

Resuscitative interventions that improve mesenteric perfusion without causing instability in systemic arterial pressures may be helpful for improving trauma patient outcomes. Blocking angiotensin II formation with enalaprilat may be such an intervention. Two questions were addressed in this two-part study investigating resuscitation from hemorrhagic shock in dogs: Can systemic arterial pressures be maintained while administering a constant rate infusion of enalaprilat during resuscitation, and can enalaprilat improve cardiovascular status during resuscitation? Animals were hemorrhaged to a mean arterial pressure (MAP) of 40 to 45 mmHg for 30 min and then 30 to 35 mmHg for 30 min. Group I (n = 5) was resuscitated to a MAP 60 to 65 mmHg with enalaprilat (0.02 mg/kg/h). Group II was resuscitated to a MAP 40 to 45 mmHg with (n = 5) or without (n = 5) enalaprilat. Resuscitation in both groups consisted of intermittent intravenous lactated Ringer's solution (60 mL/kg/h) to reach and maintain the target MAPs. Systemic arterial pressures were unaffected by enalaprilat during resuscitation in Group I, allowing us to proceed to the second study. During severely hypotensive resuscitation (Group II), systemic arterial pressures were also stable and enalaprilat administration was associated with increases (P < or = 0.02) in cardiac index (+1.2 L/min/m2), stroke volume index (SVI) (+14.5 mL/m2), superior mesenteric artery flow (+80 mL/min), stroke work (+561 mmHg/mL/m2), and left ventricular power output (+55.7 mmHg/L/min/m2). Corresponding increases were not observed in controls. We conclude that administration of a constant rate infusion of enalaprilat during resuscitation can be accomplished without causing a hypotensive crisis. Since enalaprilat significantly improved cardiovascular status including mesenteric perfusion even during intentional hypotension, it has potential value for improving the treatment of trauma patients.

Conocimientos sobre prevención del intento de suicidio en estudiantes de Medicina y médicos de familia / Knowledge about the prevention of suicide attempts in medical students and general practitioners

RESUMEN Fundamento: una práctica laboral efectiva requiere de un enfoque de competencia que muestre la relación entre aprendizaje y trabajo. Objetivo: evaluar el nivel de conocimientos que tienen los estudiantes de Medicina y médicos de familia sobre la prevención del intento de suicidio. Método: se realizó un estudio descriptivo de corte transversal en el periodo de enero 2017-2018 en el Policlínico Docente 1. "Dra. Francisca Rivero Arocha" del municipio Manzanillo, Granma. Se utilizaron métodos teóricos: histórico-lógico, análisis-síntesis e inducción-deducción; empíricos: encuesta en forma de cuestionario; y estadísticos para el procesamiento de los datos en números absolutos y el análisis porcentual. Resultados: los encuestados mostraron desconocimiento en la identificación y atención de individuos y grupos de riesgo para cometer un intento suicida; la mayoría de los estudiantes estuvieron incluidos en la categoría de Mal, en los residentes y especialistas de Medicina General Integral sobresalen las categorías de Regular, en lo fundamental. Se constataron, además insuficiencias relacionadas con el desconocimiento de los objetivos que persigue el Programa Nacional para la Prevención y Control de la Conducta Suicida. Conclusión: el diagnóstico realizado evidenció notables insuficiencias en el conocimiento acerca de la prevención del intento suicida, los autores consideran que es un problema a resolver desde la academia en el proceso de formación y superación del profesional de la Atención Primaria de Salud.

ABSTRACT Background: an effective work practice requires a competency approach that shows the relationship between learning and work. Objective: to assess the level of knowledge that medical students and General practitioners have about the prevention of suicide attempts. Method: a descriptive cross-sectional study was carried out in the period from January 2017 to 2018 in "Dr. Francisca Rivero Arocha "Teaching Polyclinic 1" from the municipality of Manzanillo, Granma province. Theoretical methods were used: historical-logical, analysis-synthesis and induction-deduction; empirical ones: survey in the form of a questionnaire; and statistics for data processing of absolute numbers and the percentage analysis. Results: the respondents showed ignorance in the identification and attention of individuals and groups at risk to commit a suicide attempt; the majority of the students were included in the category of Bad, in the residents and specialists of comprehensive General Medicine the categories of average stand out, in the fundamental thing. There were also shortcomings related to the ignorance of the objectives pursued by the National Program for the Prevention and Control of Suicidal Behavior. Conclusion: the diagnosis made evidenced notable insufficiencies in the knowledge about the prevention of the suicidal attempt; the authors consider that it is a problem to solve from the academy in the process of formation and improvement of the professional of the Primary Health Care.

Violencia doméstica en niños y adolescentes de la Comuna Tala Hady / The domestic violence of children and adolescents in the neighborhood Tala Hady

RESUMEN Fundamento: la violencia o abuso de niños y adolescentes ha sido reconocida por diversos autores como un problema complejo y creciente en los últimos años. Objetivo: describir los factores personales y familiares presentes en las víctimas sometidas a violencia doméstica en el Barrio Tala Hady, municipio de Cazenga. Métodos: la población en estudio fueron los casos denunciados y atendidos por violencia doméstica en la Delegación de la Policía en el segundo trimestre del año 2015 para un total de 31 casos. Se utilizó un cuestionario creado por los autores y el test de percepción del funcionamiento familiar (FF-SIL), fueron cumplidos los procedimientos éticos para la investigación. Resultados: predominó el sexo masculino, se destacó el grupo de 12-14 años y de 9-11 años, la mayoría tenían entre seis y ocho hermanos, lo que indicó que las familias estudiadas eran muy numerosas, referente a los tipos de violencia se encontró violencia física, violencia sexual y violencia psicológica , pero una buena parte de los casos sufrían más de un tipo de violencia, o sea, estaban expuestos a varios tipos de abuso y de agresión por padres, padrastos y madrastas, sobresalían las familias disfuncionales, donde los problemas más relevantes el abuso de alcohol u otras sustancias psicoactivas, problemas económicos y malas condiciones de vida, los factores descritos constituyen riesgo en los niños y adolescentes lo que compromete su desarrollo integral. Conclusiones: fue posible detectar la presencia de diversos tipos de violencia doméstica en la población infantil estudiada, con marcada presencia de daños físicos y psicológicos, lo que media en la problemática estudiada la disfuncionabilidad familiar, lo que da cuentas de la influencia negativa que pueden tener estas situaciones en la salud física y mental de los infantes.

ABSTRACT Background: the violence or abuse of children and adolescents has been recognized by various authors as a complex and growing problem in recent years. Objective: to describe the personal and family factors present in the victims subjected to domestic violence in the neighborhood Tala Hady, municipality of Cazenga. Methods: the study populations were cases reported and attended due to domestic violence in the Police Delegation in the second quarter of 2015, a total of 31.A questionnaire created by the authors and the family test (FF-SIL) were used, the ethical procedures for the research were fulfilled. Results: the male sex was predominant, the group of 12-14 years old and 9-11 years old stood out, the majority had between 6-8 siblings, indicating that the families studied were very numerous. Referring to the types of violence, physical violence, sexual violence and psychological violence were found, but a good part of the cases suffer more than one type of violence, that is, they were exposed to various types of abuse and aggression by parents, stepfathers or stepmothers, dysfunctional families stand out, being the most relevant problems the abuse of alcohol or other psychoactive substances, economic problems and bad living conditions. The described factors constitute risk in children and adolescents compromising their integral development. Conclusions: it was possible to detect the presence of different types of domestic violence in the child population studied, with a marked presence of physical and psychological damage, mediating the dysfunctional family in the studied problem, which accounts for the negative influence that these situations can have on the physical and mental health of infants.