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AIMS: Incomplete decongestion due to lack of titration of diuretics to effective doses is a common reason for readmission in patients with acute decompensated heart failure (ADHF). The natriuretic response prediction equation (NRPE) is a novel tool that proved to be rapid and accurate to predict natriuretic response and does not need urine collection. However, the NRPE has not been externally validated. The goal of this study was to externally validate the discrimination capacity of the NRPE in patients with ADHF and fluid overload. METHODS AND RESULTS: Patients admitted with ADHF who required intravenous loop diuretics were included. A spot urine sample was obtained ~2 h following diuretic administration, and a timed 6-h urine collection by study staff was carried out. Urine sodium and urine creatinine from the spot urine sample were used to predict the 6-h natriuretic response using the NRPE. The primary goal was to validate the NRPE to discriminate poor loop diuretic natriuretic response (sodium output <50 mmol in the 6 h following diuretic administration). The NRPE was compared with urine sodium and measured urine output which are the methods currently recommended by international guidelines to assess diuretic response. Eighty-seven diuretic administrations from 49 patients were analysed. Mean age of patients was 57 ± 17 years and 67% were male. Mean estimated glomerular filtration rate was 65 ± 28 mL/min/1.73 m2, and ejection fraction was 35 ± 15%. Median dose of intravenous furosemide equivalents administered the day of the study was 80 mg (IQR 40 - 160). Poor natriuretic response occurred in 39% of the visits. The AUC of the NRPE to predict poor natriuretic response during the 6-h urine collection was 0.91 (95% CI 0.85-0.98). Compared with the NRPE, spot urine sodium concentration (AUC 0.75) and urine output during the corresponding nursing shift (AUC 0.74) showed lower discrimination capacity. CONCLUSIONS: In this cohort of patients with ADHF, the NRPE outperformed spot urine sodium concentration and all other metrics related to diuretic response to predict poor natriuretic response. Our findings support the use of this equation at other settings to allow rapid and accurate prediction of natriuretic response.
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Up to 30% of patients with celiac disease (CD) suffer from concurrent autoimmune disease, compared to 3% of the general population. The association between CD and the current clinical phenotypes of inflammatory myopathies (IIM) patients has not been thoroughly addressed. Assess the CD features among patients with IIM and their relationship with the clinical phenotype and the myositis specific (MSA) and associated antibodies (MAA). For this cross-sectional study, we recruited 99 adult patients classified as IIM from a tertiary center in Mexico. We assessed serum MSA, MAA, and CD-associated autoantibodies (IgA anti-tissue transglutaminase (tTG) and both IgA and IgG anti-deaminated gliadin peptide (DGP)). Patients with highly suggestive serology for CD were then tested for IgG anti-endomysium antibodies, and a duodenal biopsy was performed. 70.7% of patients were positive for at least one antibody. Nine duodenal biopsies were taken, revealing findings compatible with celiac disease in two cases. Subjects with anti-MDA5 antibodies were more likely to have positive anti-tTG IgA antibodies (OR 6.76, 95% CI 1.85-24.62, P = 0.013) and suggestive CD serology (OR 6.41, 95% CI 1.62-25.29, P = 0.009). Patients with anti-Mi2 antibodies were more likely to have positive anti-DGP IgG antibodies (OR 3.35, 95% CI 1.12-9.96, P = 0.039), while positivity for these autoantibodies was less frequent in patients with anti-NXP2 antibodies (OR 0.22, 95% CI 0.06-0.80, P = 0.035). There is a higher prevalence of serologic and definite CD in patients with IIM compared to the general population. Identifying this subgroup of patients may have prognostic and therapeutic implications. Key points ⢠The study estimated a serological celiac disease (CD) prevalence of 70.7% in patients with idiopathic inflammatory myopathies (IIM) and a biopsy-confirmed prevalence of 2%, suggesting that IIM patients should be considered a high-risk population for CD. ⢠We identified a significant association between serological CD and the presence of anti-MDA5 and anti-Mi2 antibodies, suggesting a potential justification for celiac disease screening in this specific subgroup of patients. ⢠The impact of gluten-free diets on IIM patients with serological markers of CD remains untested and warrants further investigation through prospective, randomized studies.
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Autoanticorpos , Doença Celíaca , Miosite , Humanos , Doença Celíaca/epidemiologia , Doença Celíaca/imunologia , Doença Celíaca/sangue , Doença Celíaca/diagnóstico , Doença Celíaca/complicações , Estudos Transversais , Feminino , Masculino , Pessoa de Meia-Idade , Adulto , Prevalência , Autoanticorpos/sangue , Miosite/imunologia , Miosite/epidemiologia , Miosite/sangue , México/epidemiologia , Transglutaminases/imunologia , Idoso , Imunoglobulina A/sangue , Gliadina/imunologia , Imunoglobulina G/sangue , Proteína 2 Glutamina gama-GlutamiltransferaseRESUMO
BACKGROUND: Inflammation in adipose tissue, resulting from imbalanced caloric intake and energy expenditure, contributes to the metabolic dysregulation observed in obesity. The production of inflammatory cytokines, such as IL-1ß and IL-18, plays a key role in this process. While IL-1ß promotes insulin resistance and diabetes, IL-18 regulates energy expenditure and food intake. Previous studies have suggested that caspase-1, activated by the Nlrp3 inflammasome in response to lipid excess, mediates IL-1ß production, whereas activated by the Nlrp1b inflammasome in response to energy excess, mediates IL-18 production. However, this has not been formally tested. METHODS: Wild-type and caspase-1-deficient Balb/c mice, carrying the Nlrp1b1 allele, were fed with regular chow or a high-fat diet for twelve weeks. Food intake and mass gain were recorded weekly. At the end of the twelve weeks, glucose tolerance and insulin resistance were evaluated. Mature IL-18 protein levels and the inflammatory process in the adipose tissue were determined. Fasting lipid and cytokine levels were quantified in the sera of the different experimental groups. RESULTS: We found that IL-18 production in adipose tissue is independent of caspase-1 activity, regardless of the metabolic state, while Nlrp3-mediated IL-1ß production remains caspase-1 dependent. Additionally, caspase-1 null Balb/c mice did not develop metabolic abnormalities in response to energy excess from the high-fat diet. CONCLUSION: Our findings suggest that IL-18 production in the adipose tissue is independent of Nlrp3 inflammasome and caspase-1 activation, regardless of caloric food intake. In contrast, Nlrp3-mediated IL-1ß production is caspase-1 dependent. These results provide new insights into the mechanisms underlying cytokine production in the adipose tissue during both homeostatic conditions and metabolic stress, highlighting the distinct roles of caspase-1 and the Nlrp inflammasomes in regulating inflammatory responses.
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Tecido Adiposo , Caspase 1 , Caspases Iniciadoras , Interleucina-18 , Proteína 3 que Contém Domínio de Pirina da Família NLR , Animais , Camundongos , Tecido Adiposo/metabolismo , Caspase 1/metabolismo , Caspases/metabolismo , Citocinas/metabolismo , Inflamassomos/metabolismo , Resistência à Insulina , Interleucina-18/metabolismo , Lipídeos , Proteína 3 que Contém Domínio de Pirina da Família NLR/genética , Proteína 3 que Contém Domínio de Pirina da Família NLR/metabolismo , Caspases Iniciadoras/metabolismoRESUMO
Chronic heart failure continues to be one of the main causes of impairment in the functioning and quality of life of people who suffer from it, as well as one of the main causes of mortality in our country and around the world. Mexico has a high prevalence of risk factors for developing heart failure, such as high blood pressure, diabetes, and obesity, which makes it essential to have an evidence-based document that provides recommendations to health professionals involved in the diagnosis and treatment of these patients. This document establishes the clinical practice guide (CPG) prepared at the initiative of the Mexican Society of Cardiology (SMC) in collaboration with the Iberic American Agency for the Development and Evaluation of Health Technologies, with the purpose of establishing recommendations based on the best available evidence and agreed upon by an interdisciplinary group of experts. This document complies with international quality standards, such as those described by the US Institute of Medicine (IOM), the National Institute of Clinical Excellence (NICE), the Intercollegiate Network for Scottish Guideline Development (SIGN) and the Guidelines International Network (G-I-N). The Guideline Development Group was integrated in a multi-collaborative and interdisciplinary manner with the support of methodologists with experience in systematic literature reviews and the development of CPG. A modified Delphi panel methodology was developed and conducted to achieve an adequate level of consensus in each of the recommendations contained in this CPG. We hope that this document contributes to better clinical decision making and becomes a reference point for clinicians who manage patients with chronic heart failure in all their clinical stages and in this way, we improve the quality of clinical care, improve their quality of life and reducing its complications.
La insuficiencia cardiaca crónica sigue siendo unas de las principales causas de afectación en el funcionamiento y en la calidad de vida de las personas que la presentan, así como una de las primeras causas de mortalidad en nuestro país y en todo el mundo. México tiene una alta prevalencia de factores de riesgo para desarrollar insuficiencia cardiaca, tales como hipertensión arterial, diabetes y obesidad, lo que hace imprescindible contar con un documento basado en la evidencia que brinde recomendaciones a los profesionales de la salud involucrados en el diagnóstico y el tratamiento de estos pacientes. Este documento establece la guía de práctica clínica (GPC) elaborada por iniciativa de la Sociedad Mexicana de Cardiología (SMC) en colaboración con la Agencia Iberoamericana de Desarrollo y Evaluación de Tecnologías en Salud, con la finalidad de establecer recomendaciones basadas en la mejor evidencia disponible y consensuadas por un grupo interdisciplinario y multicolaborativo de expertos. Cumple con estándares internacionales de calidad, como los descritos por el Institute of Medicine de los Estados Unidos de América (IOM), el National Institute of Clinical Excellence (NICE) del Reino Unido, la Intercollegiate Network for Scottish Guideline Development (SIGN) de Escocia y la Guidelines International Network (G-I-N). El grupo de desarrollo de la guía se integró de manera interdisciplinaria con el apoyo de metodólogos con experiencia en revisiones sistemáticas de la literatura y en el desarrollo de GPC. Se llevó a cabo y se condujo metodología de panel Delphi modificado para lograr un nivel de consenso adecuado en cada una de las recomendaciones contenidas en esta GPC. Esperamos que este documento contribuya para la mejor toma de decisiones clínicas y se convierta en un punto de referencia para los clínicos que manejan pacientes con insuficiencia cardiaca crónica en todas sus etapas clínicas, y de esta manera logremos mejorar la calidad en la atención clínica, aumentar la calidad de vida de los pacientes y disminuir las complicaciones de la enfermedad.
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Insuficiência Cardíaca , Humanos , Insuficiência Cardíaca/terapia , Insuficiência Cardíaca/diagnóstico , Doença Crônica , MéxicoRESUMO
Objective: To assess the construct validity and reliability of the Trabajo en Equipo en Cirugía (TECS) questionnaire. Method: The questionnaire was administered to 401 undergraduate students who were doing surgery practices at three universities. An exploratory factor analysis was performed on the first 200 observations, and a confirmatory factor analysis on the remaining ones. The reliability of the instrument was established with Cronbach's alpha. Results: The average age of the study population was 22 years (± 1.4) and 65.5% were women. The factors "Student's disposition towards teamwork", "Structure of the work environment" and "Leadership and collaboration in the work team" showed excellent internal consistency with a Cronbach's alpha of 0.94. The results in the exploratory factor analysis showed adequate goodness of fit with the empirical data. Conclusions: The TECS is a valid (content and construct) and reliable instrument to assess the quality of teamwork in surgery in medical students.
Objetivo: Realizar la validación de constructo y el análisis de confiabilidad del cuestionario Trabajo en Equipo en Cirugía (TECS). Método: El cuestionario se aplicó a 401 estudiantes de pregrado que cursaban prácticas en cirugía en tres universidades. Sobre las primeras 200 observaciones se realizó un análisis factorial exploratorio, y sobre las restantes un análisis factorial confirmatorio. La confiabilidad del instrumento fue establecida con el alfa de Cronbach. Resultados: La edad promedio de la población en estudio fue de 22 años (± 1.4) y el 65.5% eran mujeres. Los factores «Disposición del estudiante hacia el trabajo en equipo¼, «Estructura del ambiente de trabajo¼ y «Liderazgo y colaboración en el equipo de trabajo¼ mostraron una excelente consistencia interna, con un alfa de Cronbach de 0.94. Los resultados en el análisis factorial exploratorio mostraron una adecuada bondad de ajuste con los datos empíricos. Conclusiones: El TECS es un instrumento válido (contenido y constructo) y confiable para evaluar la calidad del trabajo en equipo en cirugía en estudiantes de medicina.
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Acute heart failure (HF) is associated with poor prognosis. After the acute event, there is a vulnerable period during which the patient has a marked risk of readmission or death. Therefore, early optimization of treatment is mandatory during the vulnerable period. The objective of this article is to provide recommendations to address the management of patients with HF during the vulnerable period from a practical point of view. A group of Mexican experts met to prepare a consensus document. The vulnerable period, with a duration of up to 6 months after the acute event - either hospitalization, visit to the emergency department or the outpatient clinic/day hospital - represents a real window of opportunity to improve outcomes for these patients. To best individualize the recommendations, the management strategies were divided into three periods (early, intermediate and late vulnerable period), including not only therapeutic options but also evaluation and education. Importantly, the recommendations are addressed to the entire cardiology team, including physicians and nurses, but also other specialists implicated in the management of these patients. In conclusion, this document represents an opportunity to improve the management of this population at high risk, with the aim of reducing the burden of HF.
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INTRODUCTION: Workplace bullying and sexual harassment are concerns among general surgery residents in Colombia. OBJETIVE: To explore the prevalence and impact of workplace bullying and sexual harassment incidents among general surgery residents in Colombia. MATERIALS AND METHODS: This nationwide study was conducted in 2020. Residents selfrated their exposure to workplace bullying and to sexual harassment in the forms of gender harassment, unwanted sexual attention, and sexual coercion. We analyzed demographic variables, perpetrator's characteristics, and differences between victims and non-victims. RESULTS: The study included 302 residents. It found that 49% of general surgery residents in Colombia suffered from workplace bullying and 14.9% experienced sexual harassment. The main forms of sexual harassment were gender harassment (47%) and unwanted sexual attention (47%). Women reported significantly higher rates of being sexually harassed. Surgeons were the main perpetrators of sexual harassment. CONCLUSIONS: Workplace bullying and sexual harassment are frequent events in general surgery residency in Colombia. These findings suggest the need for interventions to improve the educational culture of surgical departments and decrease the prevalence of these behaviors.
Introducción: El acoso laboral y el acoso sexual son preocupaciones en la formación quirúrgica. Objetivo: Exploramos la magnitud de estos problemas entre los residentes de cirugía general en Colombia. Materiales y métodos: se realizó un estudio nacional en junio de 2020. Los residentes autoevaluaron su exposición a la intimidación y el acoso sexual en forma de acoso de género, atención sexual no deseada y coerción sexual. Se analizaron variables demográficas y perpetradores entre víctimas y no víctimas. Resultados: Se incluyeron un total de 302 residentes. Las tasas de acoso laboral y sexual fueron del 49% y 14,9%, respectivamente. Las principales formas de acoso sexual correspondieron al acoso de género (47%) y la atención sexual no deseada (47%). El acoso sexual fue significativamente mayor entre las mujeres. Los cirujanos fueron los principales perpetradores. Conclusiones: El acoso laboral y el acoso sexual son frecuentes en la formación quirúrgica en Colombia. Estos hallazgos conducen a intervenciones para mejorar la cultura educativa de los departamentos quirúrgicos para disminuir la prevalencia de estos comportamientos.
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Assédio Sexual , ColômbiaRESUMO
Introduction. Workplace bullying and sexual harassment are concerns among general surgery residents in Colombia. Objective. To explore the prevalence and impact of workplace bullying and sexual harassment incidents among general surgery residents in Colombia. Materials and methods. This nationwide study was conducted in 2020. Residents selfrated their exposure to workplace bullying and to sexual harassment in the forms of gender harassment, unwanted sexual attention, and sexual coercion. We analyzed demographic variables, perpetrator's characteristics, and differences between victims and non-victims. Results. The study included 302 residents. It found that 49% of general surgery residents in Colombia suffered from workplace bullying and 14.9% experienced sexual harassment. The main forms of sexual harassment were gender harassment (47%) and unwanted sexual attention (47%). Women reported significantly higher rates of being sexually harassed. Surgeons were the main perpetrators of sexual harassment. Conclusions. Workplace bullying and sexual harassment are frequent events in general surgery residency in Colombia. These findings suggest the need for interventions to improve the educational culture of surgical departments and decrease the prevalence of these behaviors.
Introducción. El acoso laboral y el acoso sexual son preocupaciones en la formación quirúrgica. Objetivo. Exploramos la magnitud de estos problemas entre los residentes de cirugía general en Colombia. Materiales y métodos. Se realizó un estudio nacional en junio de 2020. Los residentes autoevaluaron su exposición a la intimidación y el acoso sexual en forma de acoso de género, atención sexual no deseada y coerción sexual. Se analizaron variables demográficas y perpetradores entre víctimas y no víctimas. Resultados. Se incluyeron un total de 302 residentes. Las tasas de acoso laboral y sexual fueron del 49% y 14,9%, respectivamente. Las principales formas de acoso sexual correspondieron al acoso de género (47%) y la atención sexual no deseada (47%). El acoso sexual fue significativamente mayor entre las mujeres. Los cirujanos fueron los principales perpetradores. Conclusiones. El acoso laboral y el acoso sexual son frecuentes en la formación quirúrgica en Colombia. Estos hallazgos conducen a intervenciones para mejorar la cultura educativa de los departamentos quirúrgicos para disminuir la prevalencia de estos comportamientos.
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Assédio Sexual , Estresse Ocupacional , Corpo Clínico Hospitalar , Cirurgia Geral , Estudos Transversais , Discriminação SocialRESUMO
Introducción. La condición de pandemia por COVID-19 impactó a la sociedad y los sistemas de salud a nivel mundial. Las adaptaciones institucionales procuraron mantener la calidad de la atención a pesar de un contexto organizacional desfavorable. La apendicitis aguda requirió ser manejada en un nuevo escenario institucional. El objetivo de este estudio fue evaluar la efectividad del tratamiento quirúrgico de la apendicitis durante la pandemia. Métodos. Estudio observacional analítico, retrospectivo, en el que se incluyeron pacientes sometidos a apendicectomía, antes y durante la pandemia por COVID-19. Se evaluaron las complicaciones, infección del sitio operatorio, reingresos y estancia hospitalaria. Adicionalmente, se analizaron los desenlaces en los 3 picos epidemiológicos de la pandemia. Se efectuaron estadísticas descriptivas y analíticas entre los grupos a comparar. Resultados. Se incluyeron 1521 pacientes con apendicitis, 48,3 % operados antes y 51,7 % durante la pandemia. No hubo diferencias entre los grupos en complicaciones (p=0,352), infección del sitio operatorio (p=0,191), reingreso en los primeros 30 días (p=0,605) y estancia hospitalaria (p=0,514). El manejo de la apendicitis durante el tercer pico fue similar a las prácticas habituales. El tiempo de evolución fue mayor durante la pandemia (p=0,04) y los pacientes fueron llevados a cirugía más pronto que previo a la pandemia (p<0,001). Conclusiones. No se evidenció un incremento de complicaciones quirúrgicas, reingresos, estancia hospitalaria ni infección del sitio operatorio en los pacientes operados durante la pandemia. Hubo un efecto favorable para los pacientes como consecuencia de la adaptación institucional en la pandemia por COVID-19
Introduction. COVID-19 pandemic impacted society and health systems worldwide. The institutional adaptations sought to maintain the quality of care in an unfavorable organizational context. Acute appendicitis was required to be managed in a new institutional setting. The effectiveness of surgical treatment of appendicitis during the pandemic was evaluated. Methods. Retrospective analytical observational study, in patients with appendectomy, before and during COVID-19 pandemic. Complications, surgical site infections, readmissions, and hospital stay were evaluated. Additionally, the outcomes in the 3 epidemiological peaks of the pandemic were analyzed. Descriptive and analytical statistics were performed between the groups to be compared. Results. A total of 1521 patients with appendicitis were included, 48.3% before and 51.7% during the pandemic. There were no differences in complications (p=0.352), operative site infection (p=0.191), readmission at 30 days (p=0.605), and hospital stay (p=0.514) between the groups. Management of appendicitis during the 3rd peak was like usual practices. There was a long evolution time during the pandemic (p=0.04) and the patients were taken to surgery sooner than before the pandemic (p<0.001). Conclusions. There was no evidence of an increase in surgical complications, readmissions, hospital stay, and surgical site infections during patients who underwent surgery. There was a favorable effect for patients because of institutional adaptation in the COVID-19 pandemic
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Humanos , Apendicite , Avaliação de Resultados em Cuidados de Saúde , Infecções por Coronavirus , Complicações Pós-Operatórias , Pandemias , Tempo de InternaçãoRESUMO
In this study we assessed the neutrophil-lymphocyte ratio (NLR) as a predictor of steroid non-response (SNR) in patients with acute severe ulcerative colitis and found a NLR on day 3 (NLR-3) >6.1 as a suitable cutoff point to identify SNR (OR 3.44, 95%CI 1.22-9.66) with sensitivity, specificity, positive predictive value, negative predictive value, and AUROC of 66.75, 63.2%, 35.9%, 86%, and 0.650, respectively. A model including bowel movements, albumin levels, and a NLR-3>6.1 had an AUC of 0.812 to predict SNR, with acceptable calibration.