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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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Resumen Antecedentes: En México aún es muy poco conocida la epidemiología de la insuficiencia cardiaca, sin embargo se sabe que la principal causa de ingresos hospitalarios en los pacientes con insuficiencia cardiaca es la congestión pulmonar y sistémica. Objetivo: Estimar el estado de congestión y evaluar la función cardiaca mediante el ultrasonido portátil en pacientes con insuficiencia cardiaca tratados en un centro de tercer nivel en México. Método: Se llevó a cabo un estudio observacional transversal. Se seleccionaron pacientes que acudieron a la Clínica de Insuficiencia Cardiaca del Instituto Nacional de Cardiología Ignacio Chávez en la Ciudad de México entre mayo y agosto de 2022. Se les sometió a una evaluación ultrasonográfica mediante un dispositivo portátil para valorar la congestión pulmonar y sistémica, así como la función y estructura cardiaca. Resultados: Se incluyeron de forma prospectiva 100 pacientes diagnosticados con insuficiencia cardiaca en el periodo de estudio. El 76% fueron hombres, con una edad mediana de 59 años (RIQ: 50-68 años). La mediana del FEVI registrada fue del 34% (RIQ: 27.0-43.5%). Al evaluar la congestión pulmonar, el 78% de los pacientes presentaron un patrón A y el 22% un patrón B. Siguiendo el protocolo VExUS, el 92% de los pacientes mostraron un grado 0, el 2% un grado 1 y el 6% un grado 2. Conclusiones: El uso del ultrasonido portátil facilitó la caracterización cuantitativa de las características ecocardiográficas de la población estudiada. Este dispositivo podría ofrecer una mejor caracterización clínica que, a su vez, permita una optimización en la prescripción de medicamentos para la insuficiencia cardiaca y el ajuste de dosis de diuréticos según los hallazgos ecocardiográficos de congestión.

Abstract Background: In Mexico, the epidemiology of heart failure is still not well understood. However, it is known that the primary cause of hospital admissions in patients with heart failure is pulmonary and systemic congestion. Objective: To estimate congestion status and assess cardiac function using portable ultrasound in patients with heart failure. Method: A cross-sectional observational study was conducted. Patients who attended the Heart Failure Clinic at the Ignacio Chávez National Cardiology Institute in Mexico City between May and August 2022 were selected. They underwent ultrasonographic evaluation using a portable device to assess pulmonary and systemic congestion, as well as cardiac function and structure. Results: One-hundred patients diagnosed with heart failure were prospectively included during the study period; 76% were male, with an average age of 59 years (range: 50-68 years). The recorded LVEF median was 34% (IQR: 27-43.5%). When evaluating pulmonary congestion, 78% of the patients showed a pattern A and 22% a pattern B. Following the VExUS protocol, 92% of the patients were at grade 0, 2% at grade 1, and 6% at grade 2. Conclusions: The use of the portable ultrasound facilitated the quantitative characterization of the echocardiographic features of the studied population. This device could provide better clinical characterization which, in turn, might allow for optimized drug prescription for heart failure and dose adjustments of diuretics based on echocardiographic congestion findings.

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BACKGROUND: In Mexico, the epidemiology of heart failure is still not well understood. However, it is known that the primary cause of hospital admissions in patients with heart failure is pulmonary and systemic congestion. OBJECTIVE: To estimate congestion status and assess cardiac function using portable ultrasound in patients with heart failure. METHOD: A cross-sectional observational study was conducted. Patients who attended the Heart Failure Clinic at the Ignacio Chávez National Cardiology Institute in Mexico City between May and August 2022 were selected. They underwent ultrasonographic evaluation using a portable device to assess pulmonary and systemic congestion, as well as cardiac function and structure. RESULTS: One-hundred patients diagnosed with heart failure were prospectively included during the study period; 76% were male, with an average age of 59 years (range: 50-68 years). The recorded LVEF median was 34% (IQR: 27-43.5%). When evaluating pulmonary congestion, 78% of the patients showed a pattern A and 22% a pattern B. Following the VExUS protocol, 92% of the patients were at grade 0, 2% at grade 1, and 6% at grade 2. CONCLUSIONS: The use of the portable ultrasound facilitated the quantitative characterization of the echocardiographic features of the studied population. This device could provide better clinical characterization which, in turn, might allow for optimized drug prescription for heart failure and dose adjustments of diuretics based on echocardiographic congestion findings.

ANTECEDENTES: En México aún es muy poco conocida la epidemiología de la insuficiencia cardiaca, sin embargo se sabe que la principal causa de ingresos hospitalarios en los pacientes con insuficiencia cardiaca es la congestión pulmonar y sistémica. OBJETIVO: Estimar el estado de congestión y evaluar la función cardiaca mediante el ultrasonido portátil en pacientes con insuficiencia cardiaca tratados en un centro de tercer nivel en México. MÉTODO: Se llevó a cabo un estudio observacional transversal. Se seleccionaron pacientes que acudieron a la Clínica de Insuficiencia Cardiaca del Instituto Nacional de Cardiología Ignacio Chávez en la Ciudad de México entre mayo y agosto de 2022. Se les sometió a una evaluación ultrasonográfica mediante un dispositivo portátil para valorar la congestión pulmonar y sistémica, así como la función y estructura cardiaca. RESULTADOS: Se incluyeron de forma prospectiva 100 pacientes diagnosticados con insuficiencia cardiaca en el periodo de estudio. El 76% fueron hombres, con una edad mediana de 59 años (RIQ: 50-68 años). La mediana del FEVI registrada fue del 34% (RIQ: 27.0-43.5%). Al evaluar la congestión pulmonar, el 78% de los pacientes presentaron un patrón A y el 22% un patrón B. Siguiendo el protocolo VExUS, el 92% de los pacientes mostraron un grado 0, el 2% un grado 1 y el 6% un grado 2. CONCLUSIONES: El uso del ultrasonido portátil facilitó la caracterización cuantitativa de las características ecocardiográficas de la población estudiada. Este dispositivo podría ofrecer una mejor caracterización clínica que, a su vez, permita una optimización en la prescripción de medicamentos para la insuficiencia cardiaca y el ajuste de dosis de diuréticos según los hallazgos ecocardiográficos de congestión.

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Abstract Clavicle fracture represents 5% of the fractures in adults. However, segmental clavicle fractures are infrequent and have been understudied in the current literature. Cases have been reported showing adequate results with both surgical and conservative management, and yet, it has not been possible to reach a consensus regarding diagnosis or management of such condition. A patient with a middle and lateral segmental clavicle fracture is reported, after presenting multiple trauma in a road traffic accident, also suffering trauma to the right hemi body, multiple rib segmental fractures and hemothorax. After stabilization, he was taken to surgery for open reduction and internal fixation of the clavicle using a double plate technique, as it has been rarely described in the literature. The functional result was shown to be adequate and satisfactory in the postoperative follow-up. Despite the limited evidence available on the management of this type of pathology, surgical management is a valid option given the risk of non-union. The foregoing is concluded by the potential harm in patient functionality.

Resumo A fratura de clavícula representa 5% das fraturas em adultos. No entanto, as fraturas segmentares da clavícula são infrequentes e pouco estudadas na literatura atual. Há relatos de casos com bons resultados após o tratamento cirúrgico ou conservador, mas não existe consenso quanto ao diagnóstico ou manejo dessas lesões. Relata-se um paciente com fratura segmentar média e lateral da clavícula após politraumatismo em acidente de trânsito. O paciente também apresentava traumatismo em hemicorpo direito, múltiplas fraturas segmentares da costela e do hemotórax. Após estabilização, ele foi encaminhado à cirurgia para redução aberta e fixação interna da clavícula pela técnica de placa dupla, raramente descrita na literatura. O resultado funcional foi considerado satisfatório e adequado no acompanhamento pós-operatório. Apesar das poucas evidências sobre o manejo desse tipo de patologia, o tratamento cirúrgico é uma opção válida devido ao risco de não união, apesar da possível diminuição da funcionalidade do paciente.

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Worldwide, conjugated pneumococcal vaccines (PCVs) have proven effective against invasive pneumococcal disease, but non-invasive pneumonia is a major cause of mortality in young children and serotypes vary geographically, affecting effectiveness. We analyze nationwide death certificate data between 2003-2017 to assess the impact of PCVs on pneumonia mortality among young children from Peru. We report descriptive statistics and perform timeseries analysis on annual mortality rates (AMRs) and monthly frequencies of pneumonia deaths. Children under 5 years of age accounted for 6.2% (n = 10,408) of all pneumonia deaths (N = 166,844), and 32.3% (n = 3363) were children between 1-4 years of age, of which 95.1% did not report pneumonia etiology. Comparing periods before and after PCV introduction in 2009, mean AMRs dropped 13.5% and 26.0% for children between 1-4 years of age (toddlers/preschoolers), and children under 1 year of age (infants), respectively. A moderate correlation (Spearman's r = 0.546, p < 0.01) in the monthly frequency of pneumonia deaths was estimated between both age groups. Quadratic regression suggests a change in direction around 2005 (highest pneumonia mortality) for both age groups, but percentage change analysis identified an inflection point in 2013 for infants only, not for toddlers/preschoolers, suggesting that the impact of PCVs might be different for each age group.

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Pneumonia due to Streptococcus pneumoniae (pneumococcus) is a major cause of mortality in infants (children under 1 year of age), and pneumococcal conjugate vaccines (PCVs), delivered during the first year of life, are available since the year 2000. Given those two premises, the conclusion follows logically that favourable impact reported for PCVs in preventing pneumococcal disease should be reflected in the infant mortality rates (IMRs) from all causes. Using publicly available datasets, country-level IMR estimates from UNICEF and PCV introduction status from WHO, country-specific time series analysed the temporal relationship between annual IMRs and the introduction of PCVs, providing a unique context into the long-term secular trends of IMRs in countries that included and countries that did not include PCVs in their national immunisation programmes. PCV status was available for 194 countries during the period 1950-2020: 150 (77.3%) of these countries achieved nationwide PCV coverage at some point after the year 2000, 13 (6.7%) achieved only partial or temporary PCV coverage, and 31 (15.9%) never introduced PCVs to their population. One hundred and thirty-nine (92.7%) of countries that reported a decreasing (negative) trend in IMR, also reported a strong correlation with decreasing maternal mortality rates (MMRs), suggesting an improvement in overall child/mother healthcare. Conversely, all but one of the countries that never introduced PCVs in their national immunisation programme also reported a decreasing trend in IMR that strongly correlates with MMRs. IMRs have been decreasing for decades all over the world, but this latest decrease may not be related to PCVs.

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Introducción. Es un concepto generalizado que las infecciones respiratorias son estacionales, pero pocas veces se precisan localmente estos períodos de alta frecuencia en un país con diversidad de climas. Anticipar la temporada de neumonía a nivel local puede proveer de un mejor uso de recursos críticos. Objetivo. Examinar la variabilidad estacional en defunciones mensuales por neumonía en el Perú. Métodos. Estudio observacional retrospectivo de análisis de serie de tiempo para identificar períodos de alta mortalidad por neumonía en siete ciudades del Perú. Se revisaron registros administrativos del Ministerio de Salud sobre defunciones por neumonía durante los años 2003-2017. Se calcularon estadísticas descriptivas y se analizó mediante una serie de tiempo a escala mensual la frecuencia de defunciones por neumonía, precipitación acumulada, y la temperatura ambiental máxima y mínima. Resultados. El 94,4% de las defunciones por neumonía (N = 166 844) reportaron como causa "organismo no especificado", y el 75,6% eran adultos mayores de 65 años. En Tarma, Arequipa y Cusco la temperatura mínima tiene una correlación negativa con las defunciones por neumonía en todas las edades y al menos uno de los grupos de riesgo. En Iquitos la temperatura mínima tiene una correlación positiva con las defunciones en menores de 5 años. Pucallpa y Cajamarca no tuvieron correlaciones significativas. El clima de Lima es un caso particular. La distribución durante el año de las muertes por neumonía sugiere una secuencia norte-sur, mientras que el análisis espaciotemporal del clima sugiere un patrón que va de sur-norte. Conclusión. Existen diferentes patrones estacionales en diferentes ciudades y grupos de riesgo.

Introduction. It is generally accepted that respiratory infections are seasonal, but high-frequency periods are rarely identified at the local level in a country with diverse climates. Anticipating the pneumonia season locally can provide a better use of critical resources. Objective. The aim of the study was to examine seasonal variability in monthly deaths due to pneumonia in Peru. Methods. Observational retrospective study using time series analysis to identify periods of high pneumonia mortality in seven cities in Peru. We reviewed administrative reports from the Ministry of Health for pneumonia deaths during 2003-2017. Descriptive statistics were calculated and a time series analysis at a monthly scale was performed on the frequency of deaths due to pneumonia, cumulative rainfall, and maximum and minimum environmental temperatures. Results. 94.4% of pneumonia deaths (N = 166,844) were reported as pneumonia due to "unspecified organism", and 75.6% were adults older than 65 years. In the cities of Tarma, Arequipa and Cusco, minimum ambient temperature is negatively correlated to pneumonia deaths in all age groups and at least one risk group. In Iquitos, minimum temperature is positively correlated with deaths among children under 5 years of age. The cities of Pucallpa and Cajamarca reported no statistically significant correlation. The climate in Lima is a peculiar case. The distribution of pneumonia deaths throughout the year suggests a north-south sequence, while the climate space-time analysis suggests a south-north pattern. Conclusion. Results show different seasonal patterns for pneumonia deaths in different cities and risk groups.

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Background: In the projected climate change scenarios, assisted migration might play an important role in the ex situ conservation of the threatened plant species, by translocate them to similar suitable habitats outside their native distributions. However, it is unclear if such habitats will be available for the Rare Endemic Plant Species (REPS), because of their very restricted habitats. The aims of this study were to perform a population size assessment for the REPS Picea martinezii Patterson and Picea mexicana Martínez, and to evaluate the potential species distributions and their possibilities for assisted migration inside México and worldwide. Methods: We performed demographic censuses, field surveys in search for new stands, and developed distribution models for Last Glacial Maximum (22,000 years ago), Middle Holocene (6,000 years ago), current (1961-1990) and future (2050 and 2070) periods, for the whole Mexican territory (considering climatic, soil, geologic and topographic variables) and for all global land areas (based only on climate). Results: Our censuses showed populations of 89,266 and 39,059 individuals for P. martinezii and P. mexicana, respectively, including known populations and new stands. Projections for México indicated somewhat larger suitable areas in the past, now restricted to the known populations and new stands, where they will disappear by 2050 in a pessimistic climatic scenario, and scarce marginal areas (p = 0.5-0.79) remaining only for P. martinezii by 2070. Worldwide projections (based only on climate variables) revealed few marginal areas in 2050 only in México for P. martinezii, and several large areas (p ≥ 0.5) for P. mexicana around the world (all outside México), especially on the Himalayas in India and the Chungyang mountains in Taiwan with highly suitable (p ≥ 0.8) climate habitats in current and future (2050) conditions. However, those suitable areas are currently inhabited by other endemic spruces: Picea smithiana (Wall.) Boiss and Picea morrisonicola Hayata, respectively. Conclusions: Assisted migration would only be an option for P. martinezii on scarce marginal sites in México, and the possibilities for P. mexicana would be continental and transcontinental translocations. This rises two possible issues for future ex situ conservation programs: the first is related to whether or not consider assisted migration to marginal sites which do not cover the main habitat requirements for the species; the second is related to which species (the local or the foreign) should be prioritized for conservation when suitable habitat is found elsewhere but is inhabited by other endemic species. This highlights the necessity to discuss new policies, guidelines and mechanisms of international cooperation to deal with the expected high species extinction rates, linked to projected climate change.

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