Em um estudo, os autores mostraram que o EF aeróbico reduziu a pressão arterial em ratos hipertensos ao reduzir a expressão do miR-16 que tem como alvo o gene do fator de crescimento endotelial vascular (VEGF), com consequente aumento da expressão do VEGF, melhorando a função endotelial e diminuição da expressão do miR-21, com consequente aumento do seu alvo, Bcl-2, atenuando a apoptose, demonstrando assim que o EF promoveu uma alteração nos fatores angiogênicos e apoptóticos, minimizando as anormalidades microvasculares e gerando revascularização periférica na HAS.10Nesse contexto, também foi demonstrado que o EF aeróbico aumentou a expressão do miR-27a, reduzindo a expressão do seu alvo, o gene ACE, aumentou a expressão do miR-155, reduzindo a expressão do AT1R, e diminuiu a expressão do miR-153, aumentando a expressão do ACE2. Essas alterações moleculares induzidas pelo EF geraram alterações no fenótipo da artéria aorta em ratos hipertensos, como redução do peso e comprimento da aorta, redução da espessura da parede, atenuação da expressão de elastina e hidroxiprolina, com consequente melhora no relaxamento da aorta e da função endotelial, diminuindo a pressão arterial.11Em outro estudo, o EF aeróbico aumentou a expressão de miR-145 com modulação da via de sinalização AKT, induzindo a alteração do fenótipo das células musculares lisas vasculares em ratos hipertensos, diminuindo a espessura da camada média, promovendo remodelamento arterial e reduzindo a pressão arterial sistólica e diastólica.12Corroborando os estudos acima mencionados, outro estudo também mostrou que o EF reduziu a pressão arterial sistólica em ratos hipertensos, mas um aumento na expressão de miR-214 foi observado nesse estudo, exacerbando a disponibilidade de cálcio intracelular e o relaxamento de cardiomiócitos isolados.in vivo ocorrem em humanos.Assim, o EF é uma excelente ferramenta para modular a expressão de miRs e regular as vias de sinalização, induzindo alterações fenotípicas cardíacas e vasculares de longo prazo em ratos hipertensos; entretanto, esses experimentos ainda precisam ser feitos em humanos com HAS, para verificar se esses efeitos observados em estudos 13 Por outro lado, a prática regular de EF é importante para prevenir e tratar os indivíduos após IM, mas os mecanismos moleculares desses benefícios precisam ser melhor elucidados.O IM é uma condição na qual o fluxo sanguíneo é reduzido em uma ou mais artérias coronárias, resultando em redução no fornecimento de oxigênio e nutrientes para alguns cardiomiócitos, com consequente morte dessas células. O IM é considerado uma das principais causas de morbidade e mortalidade em todo o mundo.14Em relação aos efeitos do EF na expressão de miRs em modelos animais pós-IM, o EF aeróbio aumentou a expressão de miR-29a, miR-29b e miR-29c, diminuindo a expressão dos genes COL1A1 e COL3A1, reduzindo o conteúdo de colágeno no miocárdio de ratos pós-IM quantificados pela concentração de hidroxiprolina, promovendo melhora na função cardíaca avaliada por ecocardiografia.15  is beneficial for various organs and systems of the human body, mainly for the heart and cardiovascular system.3 These benefits on the cardiovascular system occur in both healthy individuals and individuals with cardiovascular diseases, such as systemic arterial hypertension (SAH)4 and myocardial infarction (MI),5 for example.In addition to the benefits for the heart, PE impacts blood vessels through shear stress and alters long-term vascular function, improving endothelial cell and smooth muscle cell function, generating arterial remodeling and a potential antiatherogenic effect.6However, the molecular mechanisms that govern these PE-induced benefits have not been completely elucidated, especially the mechanisms regulated by microRNAs (miRs), which are small non-coding RNAs that modulate the pattern of gene and protein expression in healthy individuals and those with cardiovascular diseases.Thus, the present study aims to emphasize the importance of PE in the prevention and treatment of SAH and MI, as well as explaining the role of PE-induced miRs in these pathological conditions.7 PE in turn, is extremely beneficial for individuals with SAH because it reduces pressure levels after training.8 This decrease in blood pressure is due in part to arterial remodeling, attenuating peripheral vascular resistance and also due to reduced sympathetic nerve activity.8 However, the role of miRs in reducing blood pressure remains unclear.SAH is a multifactorial disease and is associated with genetic factors and modifiable risk factors, such as a high-salt and high-calorie diet, smoking, stress, sedentary behavior and physical inactivity, being considered an independent risk factor for MI.9Few studies have demonstrated the regulatory role of miRs to reduce blood pressure. In one study, the authors showed that aerobic PE lowered blood pressure in hypertensive rats by reducing the expression of miR-16 that targets the vascular endothelial growth factor (VEGF) gene, with a consequent increase in VEGF expression, improving endothelial function and decrease in miR-21 expression, with a consequent increase in its target, the Bcl-2, attenuating apoptosis, demonstrating that PE promoted an alteration in angiogenic and apoptotic factors, minimizing microvascular abnormalities, and generating peripheral revascularization in SAH.10In this context, it was also shown that aerobic PE increased the expression of miR-27a, decreasing the expression of its target, the ACE gene, increased the expression of miR-155 reducing the expression of the AT1R and decreased the expression of miR-153, increasing the expression of ACE2. These molecular changes induced by PE, generated changes in the phenotype of the aorta artery in hypertensive rats, such as reduced aortic weight and length, decreased wall thickness, attenuation of elastin and hydroxyproline expression, with consequent improvement in the relaxation of the aorta and endothelial function, decreasing blood pressure.11In another study, aerobic PE increased the expression of miR-145 with modulation of the AKT signaling pathway, inducing the phenotype change of vascular smooth muscle cells in hypertensive rats, decreasing the medial layer thickness, promoting arterial remodeling and decreasing systolic and diastolic blood pressure.12Corroborating the abovementioned studies, another study also showed that PE reduced systolic blood pressure in hypertensive rats, but an increase in miR-214 expression was observed in this study, exacerbating the availability of intracellular calcium and the relaxation of isolated cardiomyocytes.in vivo studies occur in humans.Thus, PE is an excellent tool to modulate the expression of miRs and regulate signaling pathways, inducing long-term cardiac and vascular phenotypic changes in hypertensive rats; however, these experiments still need to be performed in human beings with SAH, to ascertain whether these effects observed in 13 On the other hand, regular PE practice is important to prevent and treat the individuals after an MI, but the molecular mechanisms of these benefits need to be further elucidated.MI is a condition in which blood flow is reduced in one or more coronary arteries, resulting in a reduction in the supply of oxygen and nutrients to some cardiomyocytes, with consequent death of these cells. MI is considered one of the main causes of morbidity and mortality worldwide.14Regarding the effects of PE on the expression of miRs in post-MI in animal models, aerobic PE increased the expression of miR-29a, miR-29b and miR-29c, decreasing the expression of COL1A1 and COL3A1 genes, reducing the collagen content in the myocardium of post-MI rats quantified by the concentration of hydroxyproline, promoting improvement in cardiac function assessed by echocardiography.15 (Another study also showed that aerobic PE exacerbated the expression of miR-29a, inhibiting the expression of TGF-β, inactivating its signaling pathway, which is pro-fibrotic. In addition to miR-29a, the authors also showed that PE increased the expression of miR-101a, which targets the FOS gene, decreasing its expression and further attenuating the TGF-β pathway. These PE-induced molecular changes resulted in reduced myocardial interstitial fibrosis in rats after MI15 .Therefore, PE has a great potential to reduce the cardiac fibrotic profile in post-MI rats through the modulation of miRs; however, these outcomes also need to be elucidated in humans, both at the molecular and tissue level.in vivo, being a promising and challenging new line of research.Finally, PE is an excellent strategy to prevent and treat individuals with SAH and post-MI. PE-modulated miRs have been described as regulators of signaling pathways inducing modification of the cardiac and vascular phenotype in hypertensive rats, promoting blood pressure reduction, physiological cardiac hypertrophy and arterial remodeling, with improved endothelial function. Furthermore, PE-modulated miRs also regulated signaling pathways associated with the cardiac fibrosis process in post-MI rats, improving cardiac function. However, these beneficial effects of PE-regulated miRs have been described in animal models, requiring clinical trials to confirm these results obtained


Esse fato levou ao conceito de “Tempo é músculo” relacionado ao manejo do infarto agudo do miocárdio (IAM).3Independentemente de qual estratégia de reperfusão é escolhida (lítica ou intervenção coronária percutânea (ICP), o tempo desde o início dos sintomas até a reperfusão bem-sucedida é fundamental para o prognóstico do paciente a curto e longo prazo.4 em ‘atraso do paciente’ e ‘atraso do sistema’, sugerindo que o último, mas não o primeiro, pode ser influenciado pelos sistemas e provedores de saúde.O tempo isquêmico total é o principal determinante do tamanho do infarto no STEMI. Ele foi dividido, desde o artigo de Terkelsen et al.,6O atraso do paciente (definido como o tempo entre o início dos sintomas e o primeiro contato médico (PCM), pode ser atribuído a várias características individuais, mas também societárias dos pacientes que apresentam STEMI e tem sido objeto de muitos estudos no passado. Depende em grande parte do conhecimento do paciente sobre os sintomas e a apresentação da doença coronariana.Por outro lado, as organizações hospitalares têm feito grandes esforços nas últimas décadas para alcançar a reperfusão oportuna das artérias coronárias ocluídas, reduzindo os tempos porta-agulha ou porta-balão e buscando modalidades melhores e mais seguras de terapias de reperfusão.No entanto, há outra fração crucial do tempo total de isquemia sempre que o PCM ocorre no ambiente pré-hospitalar. O chamado atraso do Sistema Médico de Emergência (SME) pode ter um papel importante na redução do intervalo do primeiro contato médico (PCM) até a reperfusão, seja pelo início da terapia lítica na fase pré-hospitalar ou pelo redirecionamento dos pacientes para o hospital mais próximo com instalações de ICP disponíveis, ignorando assim os hospitais regionais que podem não ter essas instalações disponíveis.7 indicam que todos os componentes do atraso do sistema (incluindo o atraso do SME) representam a qualidade do atendimento, e recomenda-se mensurá-los como indicadores de qualidade.7As diretrizes STEMI da Sociedade Europeia de Cardiologia de 2017O atraso do SME depende em grande parte das políticas das autoridades locais, regionais ou nacionais quanto à organização dos serviços de ambulância e dos protocolos implementados no atendimento pré-hospitalar da síndrome coronariana aguda.8 apresentam uma avaliação muito minuciosa da implantação de um sistema de ambulância pré-hospitalar sobre mortalidade por IAM no estado de Minas Gerais no sudeste brasileiro.8Neste número dos Arquivos Brasileiros de Cardiologia, Vieira et al.Os principais desfechos deste estudo foram as taxas de mortalidade total e intra-hospitalar por IAM e as taxas de internação por IAM. Como mencionam os autores, esses desfechos foram escolhidos devido à sua alta relevância epidemiológica e clínica e ao maior potencial de associação com a implantação do sistema de ambulância.Após um estudo muito abrangente dos múltiplos fatores que podem influenciar os desfechos do IAM durante o período 2008-2016, foi encontrada uma redução modesta (como assumido pelos autores), mas significativa na mortalidade atribuível ao IAM, e um dos principais fatores deste resultado poderia ser explicado pela implementação de um sistema de primeira resposta de ambulância pré-hospitalar.9 Eles publicaram uma análise da mortalidade por IAM nas diferentes regiões do Brasil, ao longo de 21 anos. Seus achados mostraram uma impressionante redução de 68% nas taxas de mortalidade por IAM na região Sudeste do Brasil, o que pode ser, pelo menos parcialmente, explicado pelos resultados do estado de Minas Gerais no período de sobreposição do estudo de Vieira et al.8Esses resultados estão de acordo com os relatados por Ferreira et al.,11A boa articulação entre os serviços de emergência médica e os hospitais locais/regionais, com a adoção de protocolos comuns de atendimento ao IAM e a implantação de sistemas coronarianos acelerados, são bons exemplos de políticas de saúde e iniciativas de saúde pública que se traduzem em melhores resultados após um AMI.No entanto, nem mesmo o sistema de ambulância mais bem implementado ou os melhores protocolos de atendimento pré-hospitalar darão os resultados desejados se os pacientes não ativarem oportunamente a resposta do SME.Grandes esforços devem ser feitos para educar os pacientes que apresentam sintomas que possam levantar a suspeita de ter um IAM para ligar imediatamente para o número de emergência do EMS e pedir assistência (que pode incluir o envio de uma ambulância com equipe e equipamentos adequados) em vez de ir aos serviços de saúde por meio de transporte próprio. 1Timely reperfusion of the occluded coronary arteries is critical to saving at-risk ischemic myocardial cells in acute ST-elevation myocardial infarction (STEMI). This fact led to the concept of “Time is Muscle” related to acute myocardial infarction (AMI) management.3Independently of what reperfusion strategy is chosen (lytics or percutaneous coronary intervention (PCI)), the time from symptom onset to successful reperfusion is critical to the patient's short- and long-term prognosis.4 paper, into ‘patient delay’ and ‘system delay,’ suggesting that the latter, but not the former, can be influenced by the healthcare systems and providers.Total ischemic time is the major determinant of infarct size in STEMI. It has been divided, since Terkelsen et al.6The patient delay , can be attributed to several individual, but also societal characteristics of the patients presenting with STEMI and has been the subject of many studies in the past. It largely depends on the patient's knowledge of coronary disease-related symptoms and presentation.On the other hand, hospital organizations have made large efforts in the last decades to achieve timely reperfusion of the occluded coronary arteries by reducing the door-to-needle or door-to-balloon times and looking for better and safer modalities of reperfusion therapies.However, there is another crucial fraction of the total ischemic time whenever the FMC occurs in the pre-hospital setting. The so-called Emergency Medical System (EMS) delay can play a major role in the reduction of the interval from first medical contact (FMC) to reperfusion, either by starting lytic therapy in the pre-hospital phase or by redirecting the patients to the nearest hospital with available PCI facilities, thus bypassing the regional hospitals that might not have those facilities available.7 indicate that all components of the system delay (including the EMS delay) represent the quality of care, and it is recommended to measure them as quality indicators.7The 2017 European Society of Cardiology STEMI guidelinesThe EMS delay largely depends on the local, regional, or national authorities' policies regarding the organization of the ambulance services and the implemented protocols regarding acute coronary syndrome's pre-hospital care.Arquivos Brasileiros de Cardiologia, Vieira et al.8 present a very thorough evaluation of the implementation of a pre-hospital ambulance system on AMI mortality in the state of Minas Gerais in southeastern Brazil.8In this issue of This study's main outcomes were total and in-hospital mortality rates due to AMI and hospitalization rates AMI-related. As the authors mention, these outcomes were chosen due to their high epidemiological and clinical relevance and the highest association potential with the ambulance system implementation.After a very comprehensive study of the multiple factors that might influence the AMI outcomes during the 2008-2016 period, a modest (as assumed by the authors) but significant reduction in mortality attributable to AMI was found, and one of the major factors of this outcome could be explained by the implementation of a pre-hospital ambulance first-response system.9 They published an analysis of the mortality due to AMI in the different regions of Brazil over 21 years. Their findings have shown an impressive 68% reduction in AMI mortality rates in the Southeast region of Brazil, which can be, at least partially, explained by the Minas Gerais state results in the overlapping period of the Vieira et al.8 study.These results are in line with the ones reported by Ferreira et al.11The good coordination between the emergency medical services and the local/regional hospitals, with the adoption of common protocols regarding AMI care and the implementation of coronary fast-track systems, are good examples of health policies and public health initiatives that translate into better outcomes after an AMI.However, not even the better-implemented ambulance system or the best pre-hospital care protocols will give the desired outcomes if the patients do not timely activate the EMS response.Large efforts should then be put into educating patients presenting with symptoms that might raise the suspicion of having an AMI to immediately call their EMS emergency number and ask for assistance (that might include the dispatch of an ambulance with the proper crew and equipment) rather than going to the health services by their own means of transportation.


No entanto, esses valores são baseados em medidas de consultório, monitorização ambulatorial da pressão arterial (MAPA) e monitorização domiciliar da pressão arterial (MDRA), não levando em conta a variabilidade da pressão arterial (VPA). A variabilidade interindividual da PA é um fator de risco independente para doenças cardiovasculares independentemente da PA média. 7 As flutuações nas medidas fisiológicas da pressão arterial não ocorrem aleatoriamente e podem contribuir ou ser preditores de desfechos cardiovasculares.A homeostase da pressão arterial (PA) é um elemento crucial na proteção de eventos cardiovasculares. Muitas diretrizes nacionais e internacionais 9 A VPA de curto prazo pode estar associada ao aumento do risco cardiovascular. 11A maioria dos estudos avaliou a VPA em curto (24h), médio (>2 dias) ou longo prazo . 12 os autores utilizaram dados basais de 14.357 participantes do ELSA-Brasil sem história prévia de doença cardiovascular.No estudo de Zarife et al., A VPA foi quantificada em uma única visita na linha de base pelo coeficiente de variação de três medidas padronizadas de pressão arterial sistólica usando um oscilômetro validado (Omron HEM 705CPINT) e correlacionado com o risco de DCVA. A VPA foi dividida em quartis, e o quartil mais alto foi associado a um risco cardiovascular significativamente maior em homens e mulheres. O sexo masculino apresentou maior risco cardiovascular do que o feminino em todos os quartis, sendo a maior diferença observada no quarto quartil do VPA. Além disso, a comparação dos quartis por sexo mostrou risco significativamente maior para os homens no terceiro e quarto quartis e no quarto quartil para as mulheres. A VPA também foi associada a maior velocidade de onda de pulso, menor taxa de filtração glomerular e hipercolesterolemia. Nenhum estudo relatou avaliação de risco cardiovascular e VPA em uma única visita. Os resultados do ELSA-Brasil, nesta grande coorte prospectiva, sugerem que este pode ser um marcador de risco de doença cardiovascular e ajudar a identificar pacientes que necessitam de acompanhamento mais próximo ou terapia mais intensiva. Vale ressaltar que a maioria dos participantes do ELSA-Brasil era de indivíduos normotensos (64%), reforçando o conceito de que a pressão arterial é uma medida contínua de risco e que a VPA pode ser importante não apenas para os hipertensos, mas também pode ser avaliada em indivíduos com medidas normais de pressão arterial. Outros passos devem ser a avaliação da VPB em visita única e dos desfechos cardiovasculares no ELSA-Brasil. no ELSA-Brasil. 4 have proposed target values for blood pressure, and these recommendations consider slightly different goals according to hypertension stages, risk stratification and presence of renal or cardiovascular diseases, and target organ lesion. However, these values are based on office measures, ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM), not accounting for blood pressure variability (BPV). BP intraindividual variability is an independent risk factor for cardiovascular diseases regardless of mean BP.7 Fluctuations in physiological measures of blood pressure do not occur randomly and can contribute or be predictors of cardiovascular outcomes.Blood pressure (BP) homeostasis is a crucial element in the protection of cardiovascular events. Many national and international guidelines9 Short-term BPV can be associated with increased cardiovascular risk.11Most studies evaluated BPV on short (24h), medium (>2 days) or long-term .12 the authors used baseline data from 14,357 participants of ELSA-Brasil without prior history of cardiovascular disease.In the study by Zarife et al.,BPV was quantified in a single visit at baseline by the coefficient of variation of three standardized systolic blood pressure measurements using a validated oscilometer (Omron HEM 705CPINT) and correlated with ASCVD risk. BPV was divided into quartiles, and the highest quartile was associated with a significantly higher cardiovascular risk in both men and women. Males had a higher cardiovascular risk than females in all quartiles, with the greatest difference observed in the fourth BPV quartile. In addition, comparing quartiles by sex showed a significantly higher risk for men in the third and fourth quartiles and the fourth quartile for women. BPV was also associated with higher pulse-wave velocity, lower glomerular filtration rate, and hypercholesterolemia. No studies have reported cardiovascular risk assessment and BPV in a single visit. The results from ELSA-Brasil, in this large prospective cohort suggest that this can be a marker of cardiovascular disease risk and help identify patients needing closer monitoring or more intensive therapy. It is worthy to note that the majority of participants of ELSA-Brasil were normotensive individuals (64%), reinforcing the concept that blood pressure is a continuous measure of risk and that BPV can be important not only for those with hypertension but can be assessed in subjects with normal blood pressure measures. Further steps should be assessing single visit BPV and cardiovascular outcomes in ELSA-Brasil.


VOLUME 78 ISSUE 6 - NOV/DEC 2012José Faibes Lubianca Netto • Renata Loss Drummond • Luciana Pimentel Oppermann • Fernando Stahl Hermes • Rita Carolina Pozzer KrumenauerConcerning the paper Laryngomalacia surgery: a series from a tertiary pediatric hospital, issue 78 (6), page 99, the correct name of the author is José Faibes Lubianca Neto.


Essas duas formas de aterosclerose podem ter diferenças importantes na fisiopatologia. A aterosclerose em artérias nativas está relacionada a fatores de risco cardiovascular e leva muito tempo para se desenvolver, mas após síndromes coronarianas agudas e/ou implante de stents, a inflamação sistêmica pode acelerar sua progressão,6 A neoaterosclerose intra-stent é uma forma nova e rápida de aterosclerose relacionada à lesão e inflamação vascular.4Russel Ross10 mas também a características de maior vulnerabilidade .11 A OCT abordou adequadamente todos esses aspectos. As descobertas do artigo têm implicações importantes:Complicações como a ruptura da placa aterosclerótica parecem estar associadas não apenas à expansão da placa,131) A necessidade de terapia apropriada  para prevenir o desenvolvimento de aterosclerose em artérias coronárias nativas e possivelmente na aterosclerose intra-stent.152) O estudo levanta o debate sobre a relevância do risco inflamatório residual e a oportunidade do uso de anti-inflamatórios.3) Mais estudos são necessários para entender melhor a neoaterosclerose intra-stent e a necessidade de estratégias mais abrangentes, para prevenir esta forma de falha do stent. Arquivos Brasileiros de Cardiologia, Pinheiro et al.1 show optical coherence tomography (OCT) data with clear differences in inflammation and neovascularization among de novo atherosclerosis, in-stent restenosis due to intimal hyperplasia, and in-stent neoatherosclerosis.In this edition of 2 minimized by current techniques and stents of new generation.3 However, the neointimal lesion secondary to a delay in neoendothelialization can lead to symptom recurrence, usually during the first year of coronary intervention.4Patients undergoing percutaneous coronary intervention with stent implantation may have recurrent symptoms of coronary heart disease due to in-stent restenosis due to vascular injury that triggers an intimal proliferative response,5 contributing to plaque instability6 and infarcted mass and ventricular remodeling after myocardial infarction.7 In addition, stent implantation also promotes systemic and local inflammation.8In patients with acute coronary syndromes, pronounced inflammatory responses can be detected for weeks,9 defined atherosclerosis as an inflammatory disease.9 Pinheiro et al.1 reported increased inflammatory activity and neovascularization among de novo lesions and intra-stent neoatherosclerosis. These two forms of atherosclerosis may have important differences in pathophysiology. Atherosclerosis in native arteries is related to cardiovascular risk factors, and it takes a long time to develop, but after acute coronary syndromes and/or stent implantation, systemic inflammation may accelerate its progression.6 Intra-stent neoatherosclerosis is a new and fast form of atherosclerosis-related to vascular injury and inflammation.4Russel Ross10 but also with characteristics of greater vulnerability .11 OCT has properly addressed all these aspects. The article’s findings have important implications:Complications such as atherosclerotic plaque rupture seem to be associated not only with plaque expansion13The need for appropriate therapy (including highly-effective lipid-lowering therapies) to prevent the development of atherosclerosis in native coronary arteries and possibly in the intra-stent atherosclerosis.15The study raises the debate about the relevance of residual inflammatory risk and the opportunity to use anti-inflammatory drugs.More studies are necessary to understand better intra-stent neoatherosclerosis and the need for more comprehensive strategies, to prevent this form of stent failure.


É esperado que haja um aumento na sua medida até o limiar anaeróbico e este se correlaciona a um aumento do débito cardíaco.A medida da pressão de dióxido de carbono no final de expiração  e do VE/VCO2 slope (35), foram semelhantes a valores descritos previamente na literatura16, não havendo diferença nos pacientes com e sem TRC.14 É importante ressaltar que, nesse estudo observacional, não houve diferença na incidência de eventos cardiovasculares maiores entre os pacientes com e sem TRC. Outro achado importante foi o excelente valor preditivo negativo (VPN) de medidas de PETCO2, VO2pico e VE/VCO2 slope nos seus pontos de corte, mais evidente ainda nos pacientes do grupo TRC.No estudo de Reis et al.,2 pico para a predição de eventos. Entretanto, as evidências fornecidas, além de consolidar o papel prognóstico do TCPE nesses pacientes, chamam atenção para a importância da medida do PETCO2LA rotineiramente nesses casos. O uso dessa variável apresenta excelente poder prognóstico e pode adicionar informações às medidas tradicionais do TCPE. A sua medida apresenta excelente relação com o aumento do débito cardíaco ao esforço, e uma resposta alterada (ausência de aumento até o LA) caracteriza maior prejuízo no aumento do débito no exercício.Uma possível limitação do estudo, já mencionada pelos autores, é a presença de testes submáximos em uma quantidade razoável de pacientes, o que reduz o poder discriminatório do VOETCO2LA nos pacientes com IC e comparando-o às outras medidas prognósticas são bem-vindos. A replicação de resultados em populações distintas fortalece a evidência encontrada e amplia a validade externa dos achados encontrados.Estudos com maior tamanho amostral, preferencialmente multicêntricos, avaliando o poder prognóstico do P 1 with reduced ejection fraction (HFrRF), being a cornerstone in the evaluation for the indication of advanced therapies in HFrEF.2 Cardiac resynchronization therapy (CRT), in addition to reducing mortality, can improve cardiorespiratory fitness, leading to an increase in peak oxygen consumption (VO2peak) and a reduction in the slope of the respiratory equivalent CO2 ratio (VE /VCO2 slope).5 In recent years, with the evolution of treatments, general mortality and the risk of the sudden death of patients with HFpEF have been reduced.7 In this context, reviewing the prognosis and the values associated with a higher risk among the CPET variables in patients undergoing CRT becomes important.The cardiopulmonary exercise test (CPET) is a consolidated tool in the functional and prognostic assessment of patients with heart failure8 and at the first ventilatory threshold or anaerobic threshold (PETCO2LA),9 has a well-established prognostic value in heart failure.9 The increase of dead space ventilation, caused by the impairment of the ventilation/perfusion (V/Q) ratio, for example, in patients with left ventricular dysfunction, leads to a reduction in alveolar CO2 and, consequently, in PETCO2. It is expected that there will be an increase in its measurement up to the anaerobic threshold, which is correlated with an increase in cardiac output.The measurement of end-tidal carbon dioxide pressure (PETCO2) during CPET, both at rest,Arquivos Brasileiros de Cardiologia , Reis et al.10 present an interesting analysis of the prognostic role of CPET in a cohort of 450 patients, 114 of whom underwent CRT.10 The patients were followed up for 2 years, and the evaluated outcome was cardiovascular mortality and the need for urgent transplantation. The classic evaluation studies for heart transplantation11 involving CPET do not include patients with CRT, which makes it important to question how the behavior of prognostic variables would be in this context.11 Knowledge of this scenario is scarce, and some evidence suggests a less important role of peak VO2in these patients in the selection for heart transplantation.12In this issue of 10 VO2peak, VE/VCO2 slope,PETCO2 and PETCO2LAwere able to predict outcomes in patients with HF and CRT in uni- and multivariable analyses.10 However, in the ROC curve analysis, PETCO2LAapparently showed superior accuracy for predicting events. Interestingly, the optimal cut-off point was 33 mmHg, lower than the 36 mmHg in previous studies that evaluated this variable.13 On the other hand, the cut-off points for peak VO2(12 ml/kg/min) and VE/VCO2 slope (35) were similar to values previously described in the literature16, with no difference in patients with and without CRT.14 It is important to emphasize that, in this observational study, there was no difference in the incidence of major cardiovascular events between patients with and without CRT.In the study by Reis et al.,2 for predicting events. However, the evidence provided, in addition to consolidating the prognostic role of CPET in these patients, calls attention to the importance of routinely measuring PETCO2LAin these cases. This variable has excellent prognostic power and can add information to traditional CPET measurements. Its measurement has an excellent relationship with the increase in cardiac output on exertion, and an altered response (absence of increase up to the AT) characterizes a greater loss in the increase in output during exercise.A possible limitation of the study, already mentioned by the authors, is the presence of submaximal tests in a reasonable number of patients, which reduces the discriminatory power of peak VOETCO2LAin patients with HF and comparing it to other prognostic measures are welcome. The replication of results in different populations strengthens the evidence found and expands the external validity of the findings.Studies with larger sample sizes, preferably multicenter, evaluating the prognostic power of P


Diversity, Equity, and Inclusion in Action: Planning, Leadership, and Programming as well as a product review of Polyglot Search Translator designed to support your systematic searching.It is spring! I am excited to see the signs of spring and say goodbye to the extended cold temperatures of this winter. I know many of you are also. Along with spring comes the April issue of JCHLA/JABSC. We have a great line up this issue including two research papers. The first looking at developing a code of practice for mediated searching. The second looks at mobile device use by medical learners. We also have a number of book and product reviews two of which include a review of the book  DataSharing Policy and our Data Sharing FAQ.This April is of particular importance as it concludes the 1-year-trial period of our JCHLA/JABSC Data Sharing Policy. Please note all submissions going forward will be required to follow this policy. For more information view our Author Guidelines for more on how your work could be featured in our journal.Lastly, don’t forget to register for this year’s CHLA/ABSC Conference 2022. For details you can find an announcement from the Conference Planning Committee in this issue. We’re looking forward to an inspiring program. If you’re presenting a paper or poster, we’d like to invite you to consider submitting it to JCHLA/JABSC – see ourAlanna CampbellJCHLA/JABSC Editor-in-Chiefeditor@chla-absc.caEmail: Diversity, Equity, and Inclusion in Action : Planning, Leadership, and Programming ainsi qu'une revue du produit Polyglot Search Translator, pour le soutien aux recherches systématiques.C'est le printemps ! J'ai hâte d’en voir les signes durables et de dire adieu aux températures froides prolongées de cet hiver. Je sais que beaucoup d'entre vous partagent ce sentiment. Avec le printemps vient le numéro d'avril du Journal de l’Association des bibliothèques en santé du Canada / Journal of the Canadian Health Libraries Association (JABSC / JCHLA). Nous proposons un grand choix d’articles pour ce numéro, y compris deux articles de recherche. Le premier porte sur le développement d'un code de pratique pour la recherche médiatisée. Le second porte sur l'utilisation des appareils mobiles par les étudiants en médecine. Nous avons également un certain nombre de critiques de livres et de produits, dont deux présentent une critique du livre lapolitique de partage des données et la chronique FAQ sur le sujet.Ce mois d'avril revêt une importance particulière, car il conclut la période d'essai d'un an de la politique de partage des données du JABSC / JCHLA. Veuillez prendre note que dorénavant toutes les soumissions devront suivre cette politique. Pour plus d'informations, nous vous invitons à consulter directives pour les auteurs afin de savoir comment votre travail pourrait être présenté dans notre journal.Enfin, n'oubliez pas de vous inscrire au congrès 2022 de l'ABSC / CHLA. Pour plus de détails, vous trouverez une annonce du comité de planification de la conférence, dans ce numéro. Nous attendons avec impatience un programme stimulant. Si vous présentez une communication ou une affiche, nous vous invitons à considérer la soumettre au JABSC / JCHLA - consultez nos Alanna CampbellRédactrice en chef, JABSC / JCHLAeditor@chla-absc.caCourriel:


To determine the factors related to overall healthcare costs of road traffic accidents in Bucaramanga, Colombia. A descriptive cross-sectional study was conducted through the analysis of road traffic accident records that took place in 2019 in Bucaramanga, Colombia. Cost quartiles in dollars were compared using Pearson’s chi-squared and Fisher’s exact tests. Odds ratios were also calculated in logistic regression. 3,150 road accidents were reported in 2019 involving 7,038 people, of which 812 had information related to healthcare costs in health care institutions. The median cost was 56.59 USD (RI = 29.35–140.15), average cost of 290.11 USD ± 731.22 (95%CI: 239.74–340.48). A higher possibility to be in the 4th quartile was found when persons were under 18 years of age  or 46–60 years , the type of vehicle involved is motorcycle , bicycle , having a head injury  and hypothetical drunk driving . Relevant factors in healthcare costs were riding a motorcycle or bicycle, having a head injury, being under 18 years of age or 46 to 60 years of age and hypothetical drunk driving. It is important to implement prevention measures based on identified factors to reduce road accident rate and therefore, its socioeconomic costs. Mortality due to this matter was 18.3 and years of life lost was 817.4 per 100,000 inhabitants.Traffic accidents or crashes represent a worldwide public health problem. The global burden of disease from road traffic crashes or accidents was 877.4 per 100,000 inhabitants (age-standardized rate) in 2016, being more frequent in Central and Eastern European countries.In Colombia, during 2019 the rate of traffic accidents was 1,214, with a mortality rate of 14.6 (95%CI: 11.1–18.6) per 100,000 inhabitants, the latter corresponds to 3.13% of the total deaths in the country, positioning it as the ninth cause of death. Mortality is higher in men  than in women ; it is also more frequent in people over 70 years of age. Likewise, the years of life lost were 701.7 per 100,000 ihabitants, which places it in sixth place suggests that factors can be classified into three stages: before, during and after the event. In addition, factors can be grouped into individual factors , vehicle factors (equipment and protection elements) and environmental factors (climatic factors and infrastructure), some of which can be opportunities for public health research and intervention.Many factors can be associated with traffic accidents occurrence. A classification conducted in Mexico.In addition, timely emergency care saves lives and reduces disabilities. It is estimated that if low-and middle-income countries had the same mortality rates from severe injuries that of high-income countries, 500,000 deaths caused by road crashes could be avoided each year. The above is to reduce deaths and disabilities due to road traffic injuries, lower socioeconomic costs related to countries, families and individuals, have more efficient and effective use of existing healthcare resources at all levels of the system and expand emergency care capacity and resilience of the system to maintain service provision even during crashes with multiple victims.In this light, emergency care  should involve basic aspects such as ensuring access to emergency care, providing main structural components for prehospital care, implementing basic emergency service packages at each level of care, creating a national lead agency and evaluating the emergency care system. In Colombia, although healthcare service costs are covered by the Compulsory Traffic Accident Insurance (SOAT for its acronym in Spanish), which must be purchased for each vehicle, sometimes this insurance is not enough to cover these costs. Therefore, after exceeding insurance coverage limits, the bill is covered by health promoting entities. In Bogotá, healthcare costs of traffic accidents were estimated at $1,112,000 COP per patient ($278 USD), inpatient day at $1,200,000 and outpatient care at $247,400 COP.Traffic accidents are estimated to take about 1 to 4% of the gross domestic product (GDP) in developing countriesAs previously described, this study was meant to determinate the different factors related with the total costs generated during heath care attentions for traffic accidents in Bucaramanga, Santander, Colombia, during 2019.A descriptive cross-sectional study was conducted by analyzing secondary data from traffic accident records in Bucaramanga in 2019 provided by the Traffic Directorate and the Municipal Digital Observatory of Bucaramanga using census sampling.Based on 7,038 records from people involved in 3,150 traffic accidents that took place in Bucaramanga during 2019 reported by the Traffic Directorate and the healthcare data reported by the Municipal Digital Observatory from healthcare provider institutions, it was possible to obtain costs for 812 people treated in multiple healthcare institutions around the city. Databases were extracted, cleaned-up and cross-referenced afterward .The dependent variable was direct healthcare costs  reported by healthcare institutions to the Bucaramanga Secretary of Health, including medical examination/care , diagnostic aids  and treatments In addition, the following covariates were considered: identifier, gender , age , type of vehicle involved , accident hypothesis , place of occurrence, bearing a driving license and compulsory traffic accident insurance, location of healthcare institution, severity, date of occurrence, day of the week , district, healthcare provider institution, surgery requirement, death, affected body part , diagnosis, road users and general healthcare costs in Colombian pesos.Variables were described by using proportions of qualitative variables, average, standard deviation, median and interquartile range according to the normal distribution of quantitative variables. The variable “costs” was converted into dollars . Quartiles were calculated afterward. Differences between quartiles were studied in relation to the variables age, sex, type of vehicle involved, day of the week, accident hypothesis, bearing a driving license and mandatory traffic accident insurance, affected body part, in addition to other traffic accident variables through Pearson’s chi-square and Fisher’s exact tests. Statistical significance was considered when the p-value was < 0.05.Odds ratios were calculated by logistic regression, representing an increase in the possibility of being in the 4th quartile at a 95% confidence interval for the category of interest with respect to the reference category (assigned as “1”). As for the affected body part variable, the reference was several parts of the body when referring to injuries in several parts of the body. Data analysis was performed using the Stata 11.0 software Universidad de Santander(UDES) by the University Ethics Committee (Minutes 019 of 2019) and theEmpresa Social del Estado Hospital Universitario de Santander- HUS  as recorded in Minutes 09 of 2019, classified as a minimal risk study according to the Colombian regulations, Resolution 8430 of 1993 by the Ministry of Health. Data was processed in accordance with the provisions of the Colombian Statutory Law 1581 of 2012 (Habeas Data Law), which establishes personal data protection regulations.The project was approved under an internal call for proposals (code CIF0315-19) at theAccording to the Municipal Traffic Directorate, 7,038 people were involved in 3,150 traffic accidents in 2019. Of these people, a high proportion was male at 88.48%  and 29.67%  were in the 26–35 age range. Median age was 34 years of age (RI = 26–46). In addition, 81.15%  had a driving license and 93.81%  had compulsory insurance. The most relevant accident hypotheses were failure to obey traffic signals and rules, failure to keep a safe distance, making a sharp turn, driver inexperience and speeding, respectively. Regarding the type of vehicle involved, cars and motorcycles were the most relevant. Saturdays and Tuesdays had the highest number of people injured in accidents . In addAccording to the records provided by healthcare provider institutions in Bucaramanga, 874 people were admitted in 2019 from which it was possible to identify the most common body part affected in 665 people, being lower limbs, upper limbs, thorax and head the most affected parts, respectively .Regarding costs, data from 812 people injured in traffic accidents helped to identify a median of $56.59 USD  and an average of $290.11 USD ± 731.22 (95%CI: 239.74–340.48).Differences were observed in relation to the distribution of some sociodemographic variables among quartiles. Regarding gender, no significant differences were identified among quartiles. However, male gender had percentages higher than 83% in all quartiles. Regarding age, significant differences were identified  in which people under the age of 18 accounted for 10.84% (22) in the fourth quartile but lower than 7% in other quartiles. In addition, people between 46 and 60 years accounted for 13.79% (28) in the fourth quartile but lower than 10.50% in other quartiles. Thus, the ORs are significant for these two categories, compared to those over 60 years of age .Regarding variables related to regulatory compliance, those who bear a driving license and mandatory insurance represented a lower percentage in Q4 than Q1-Q3. Here, ORs are protective and their confidence intervals are less than “1”. According to the severity reported by Municipal Traffic Directorate officials based on the people who attended healthcare institutions in Bucaramanga, 92.24% (749) were classified as injured, 1.60% (13) died and 6.16% (50) had no severe injuries. The ORs and CIs of the latter two categories are less than 1.Regarding accident hypothesis, no statistically significant differences were found that could affect costs when comparing quartiles. However, ORs were 12.44 (95%CI: 2.01–76.87) for people with hypothetical drunk driving .The main type of vehicle involved in patients attending healthcare institutions is motorcycle, having percentages higher than 83% in every quartile. Bicycles also ranked second having 7.88% in Q4. Thus, ORs identified were 2.79 (95%CI: 1.25– 6.24) and 7.66 (95%CI: 2.70–21.68) when comparing accidents involving cars.Regarding body part affected, 33.33% (53) were head injuries having the highest proportion in Q4, followed by lower limb injuries at 20.13% (32). OR in head injuries was 4.50 (95%CI: 2.61–7.76) compared to the category involving other body parts .; most affected body parts are head and limbs, from which cranioencephalic trauma is highly associated with mortality; and disobeying traffic rules and reckless driving were found to be as risk factors.Only a few studies have reported characteristics and costs of road traffic injuries. In Colombia, few studies have described incidences, associated factors and injury characteristics in these events, reporting that motorcyclists suffer the most injuries.In our study, many traffic accidents involved young men bearing a valid driving license but did not follow traffic signals/rules or speed, which is consistent with the findings reported by other authors. However, according to the data from those attending healthcare institutions, the main vehicle involved was motorcycle as same as in other studies.Regarding the type of vehicle involved, cars were found to be in the first place after motorcycles.Regarding injuries, in our study the most common body parts affected were upper limbs, lower limbs and head, in contrast to a study conducted in Brazil in which head injuries were identified as the most common body part affected. However, only motorcycle accidents were analyzed in the latter. However, our study did not include indirect costs and costs of lost productivity derived from accidents, which according to other studies have shown to be higher than those purely related to healthcare due to accidents.In addition, the median cost per traffic accident was $56 USD (RI = 29.35–140.15) and the average was 290.11 ± 731.22, (95%CI: 239.74–340.48) only for medical expenses derived from in-patient care, which could be considered low compared to a study conducted in Iran where the average cost is $9,024 USD.Thus, costs derived from traffic accidents may have a social and economic impact on the community. Therefore, it is important to adopt preventive measures aimed at reducing their occurrence. One of these measures is to take actions to reduce traffic congestion as some studies have found that high levels of congestion can increase accident probability as a result of having more cars on the road. However, it should be considered that accidents are also frequent in low levels of congestion as a result of speeding. The latter suggests the need to intervene in regulations and speed controls on the roadRegarding this finding, it is suggested to continue exploring the effects of traffic congestion on road accidents, given the results shown in this study, such as failure to yield the right of way, overtaking by encroaching, overtaking on the right and making sharp turns, could indicate a behavior resulting from rushing or haste after a period of vehicular traffic.. A statistically significant relationship was also observed between injury severity and cost increase, similar to that reported in a study in Haiti where patients injured in road accidents represented the highest cost averaging $1,220 USD.In our study, a statistically significant relationship was found between traffic accident costs and age, possession of a valid driving license and insurance, road accident severity based on the classification made by the traffic directorate and affected body parts, similar to that reported in a study conducted in Iran. In Colombia, theUniversidad de los Andes estimated traffic accident costs to be close to 1% of GDP between 2008 and 2010. The above included medical, human and administrative costs, as well as economic losses due to property damage. In 2016, traffic accident costs incurred by the Compulsory Traffic Accident Insurance and the Administrator of the Resources of the General System of Social Security in Health were estimated at 1.5 COP billion per year.In Argentina, Brazil, Colombia and Mexico, cumulative GDP loss was estimated at 13.540 USD million between 2006 and 2015 due to frequent chronic noncommunicable diseases, heart disease, stroke and diabetes where this condition was considered a factor for increased sequelae and therefore, increased costs due to loss of production capacity.Although our study did not find a statistically significant relationship between gender and costs, a higher number of accidents involved men, which could be considered a risk factor and focus of preventive measures in this population, as identified in Brazil as a way to monitor and re-educate drivers. This would reduce traffic accident expenses in the healthcare system and the community, enabling resource allocation to supply other basic needs of the population and thereby likely reducing the nation’s economic burden.Study results showed the need to have a prevention focus on the most frequent factors identified in traffic accidents such as male gender, young age, motorcycle as vehicle type and the prevalence of some inappropriate driving behaviors, which are not related to having a valid driving license insurance documentation. This suggests that educational actions should be focused on generating collective awareness to change risk behaviors in accidents. It is worth noting that several countries are now implementing a point-based driving licenseThis study had some recognized limitations such as the lack of information from healthcare institutions located in other municipalities of the metropolitan area . In addition, as for the ICD-10 data reported by healthcare institutions, 209 records did not provide any information on the body part that was specifically affected, assigning ICD-10 to the road user , besides breaking down costs of direct medical care by professionals, medications, transportation, diagnostic aids and devices. In addition, analyzing the quality of motorcycles, personal protective equipment and their proper use is highly suggested.In addition, generated costs may be lower given that human and technological resources for healthcare may be lower than those of developed countries. In addition, in future studies it will be worth linking variables such as alcohol intake, road conditions where traffic accidents occurred, use of personal protection, complications due to surgical procedures and analysis of indirect costs such as loss of production capacity due to sequelae after accidents, thus providing a broader view for budget allocation and rates foreseen by insurance companies to cover these events, as suggested in other studiesFinally, a considerable increase in traffic accident costs was identified when the type of vehicle involved is motorcycle or bicycle, the age of the injured person is under 18 years of age or between 46 and 60 years of age, affected body part is head and accident hypothesis is drunk driving. In contrast, a decrease in traffic accident costs was identified when the driver complied with bearing a regulatory driving license and mandatory accident insurance policy. Identifying mechanisms to reduce these types of events is highly relevant as traffic accidents can be preventable, measures can be implemented to reduce their severity and therefore, their costs and consequences for society. . La mortalidad por esta problemática fue de 18,3, y los años de vida perdidos fueron 817,4 por cada 100.000 habitantes.Los accidentes o siniestros de tránsito representan un problema de salud pública mundial. En el 2016, la carga global de la enfermedad por siniestros de tránsito fue de 877,4 por cada 100.000 habitantes (tasa estandarizada por edad), siendo más frecuente en los países de Europa central y oriental.En Colombia, durante el año 2019 la tasa de siniestros de tránsito fue de 1.214, con tasa de mortalidad de 14,6  por 100.000 habitantes, esta última corresponde al 3,13% del total de muertes en el país, posicionándose en la novena causa de muerte. La mortalidad es mayor en hombres con 24 por 100.000 hab. que en mujeres 5,9 por 100.000 hab.; también, es más frecuente en personas mayores de 70 años de edad. Asimismo, los años de vida perdidos fueron 701,7 por 100.000 habitantes, lo cual lo ubica en el sexto lugar, se plantea que se pueden subdividir en tres momentos: antes, durante y posterior al evento. Además, los factores se agrupan en individuales , del vehículo (elementos de equipamiento y protección) y del ambiente (factores climáticos e infraestructura), algunos de estos factores son oportunidades de investigación e intervención en salud pública.Son múltiples los factores que pueden asociarse con el desarrollo de los siniestros de tránsito. En una clasificación realizada en México.Por otro lado, la atención oportuna de emergencias salva vidas y reduce las discapacidades. Se estima que si los países de medios y bajos ingresos tuvieran las mismas tasas de letalidad derivadas de traumatismos graves que los países de ingresos altos, se podrían evitar cada año 500.000 defunciones causadas por accidentes de tránsito. Esto permite reducir las defunciones y discapacidades debidas a traumatismos por siniestros de tránsito, disminuir los costos socioeconómicos vinculados para los países, las familias y las personas, uso más eficiente y eficaz de los recursos de atención sanitaria existentes en todos los niveles del sistema y mayor capacidad de atención de emergencia y resiliencia del sistema para mantener la prestación del servicio aun en casos de accidentes con múltiples víctimas.En este sentido, la atención de las emergencias  debe involucrar los siguientes aspectos básicos: garantizar el acceso a la atención de emergencias; garantizar los principales componentes estructurales de la atención prehospitalaria; establecer un paquete básico de servicios médicos de emergencias para cada nivel de atención; establecer un organismo director a escala nacional; y realizar evaluación del sistema de atención de emergencias. En Colombia, los gastos de la atención de servicios de salud son asumidos por el Seguro Obligatorio para Accidente de Tránsito (SOAT), el cual es adquirido para cada automotor, en ocasiones este rubro no es suficiente para cubrirlos, por lo tanto, después de pasar ese límite, la cuenta es asumida por las Entidades Promotoras de Salud. Los costos de la atención de los accidentes de tránsito en Bogotá en 2013 fueron estimados en promedio por paciente en $1.112.000 pesos colombianos (en dólares US$ 278), el día de hospitalización en $1.200.000 y pacientes con atención ambulatoria en $247.400.Se estima que los siniestros de tránsito consumen entre el 1% al 4% del producto interno bruto (PIB) en países en desarrolloPor lo anteriormente descrito, en este estudio se pretende determinar los factores relacionados con los costos totales generados durante la atención en salud de los siniestros de tránsito en Bucaramanga, Santander, Colombia, durante el 2019.Este es un estudio descriptivo, transversal, con análisis de datos secundarios provenientes de los registros de accidentes de tránsito de Bucaramanga en 2019, proporcionados por la Dirección de Tránsito y el Observatorio Digital Municipal de Bucaramanga, muestreo tipo censo.Con base en los 7.038 registros de personas involucrados de un total de 3.150 siniestros de tránsito ocurridos en Bucaramanga en 2019 reportados por la Dirección de Tránsito y la información de atención en salud del Observatorio Digital Municipal de Bucaramanga a partir de las diferentes instituciones prestadoras de salud (IPS), se obtuvo información de costos de 812 personas atendidas en las IPS de la ciudad; posteriormente, se realizó la extracción, depuración y cruzamiento de las bases de datos .La variable dependiente fue costos directos derivados de la atención en salud , que las IPS reportaron a la Secretaría de Salud de Bucaramanga que incluyen la valoración/atención , las ayudas diagnosticas  y tratamientos instaurados .Además, se tuvieron en cuenta las siguientes covariables: identificador, genero , edad , tipo de vehículo involucrado , hipótesis del accidente , lugar de ocurrencia, porte de licencia, porte del seguro obligatorio de accidente de tránsito, sitio de atención en salud, gravedad, fecha de ocurrencia, día de la semana , comuna, instituciones prestadoras de servicios de salud, requerimiento de cirugía, muerte, parte del cuerpo afectada , diagnóstico, actor vial y costo general de la atención en salud en pesos colombianos.La descripción de las variables se realizó por medio de proporciones para variables cualitativas; promedios, desviación estándar, mediana y rango intercuartílico según la distribución normal o no de las variables cuantitativas. La variable costos se transformó a dólares, 4.000 pesos colombianos equivalen a 1 dólar según la tasa representativa del mercado a 31 de marzo del 2020 de la Superintendencia Financiera de Colombia, posteriormente, se calcularon sus cuartiles. Se exploraron diferencias entre los cuartiles con relación a las variables edad, sexo, tipo de vehículo involucrado, día de la semana, hipótesis de accidente, porte de licencia de conducción, porte de seguro obligatorio de accidentes de tránsito, parte del cuerpo afectada, además de otras variables del accidente de tránsito, a través de las pruebas estadísticas de chi-cuadrado de Pearson y exacta de Fisher. Se consideró significancia estadísticamente significativa cuando el valor de p es < 0,05.odds ratio(OR) con sus respectivos intervalos de confianza del 95% mediante regresión logística. Los OR representan la razón de posibilidades de estar en el último cuartil (Q4) de costos para la categoría de interés respecto a la categoría de referencia (se representa con el número “1”) de la variable evaluada. Para la variable parte del cuerpo afectada la categoría de referencia fue diferentes partes del cuerpo, la cual fue construida cuando los participantes referían lesiones en varias partes del cuerpo. El análisis de datos fue realizado con el software Stata 11.0 .También, se calcularonEl proyecto fue aprobado por la convocatoria interna de la Universidad de Santander (UDES) con el código CIF0315-19, por el Comité de Bioética de la Universidad de Santander (Acta 019 de 2019) y de la Empresa Social del Estado Hospital Universitario de Santander (HUS) (Acta 09 de 2019). El estudio fue catalogado como riesgo mínimo según la normatividad colombiana, Resolución 8430 de 1993 del Ministerio de Salud. El manejo de los datos se realizó conforme a lo estipulado por la Ley Estatutaria 1581 de 2012, Habeas Data de Colombia, que establece la protección de los datos personales.Según la Dirección de Tránsito Municipal, hubo 7.038 personas involucradas en 3.150 siniestros de tránsito durante 2019. De las personas involucradas, la mayor proporción corresponden al género masculino con el 88,48% (6.227) y rango de edad entre 26 y 35 años el 29,67% (2.088); mediana de edad de 34 años (RI = 26–46). Además, se tiene registro de que portaban la licencia de conducir el 81,15% (5.711) y el seguro obligatorio el 93,81% (6.602). Las hipótesis de accidentes más relevantes fueron desobedecer señales y normas de tránsito, no mantener la distancia segura, girar bruscamente, impericia al manejo y exceso de velocidad, en su orden. Con relación al tipo de vehículo involucrado, los más relevantes fueron automóvil y motocicleta. Los días sábado y martes fueron los que presentaron mayor número de personas lesionadas por estos eventos . AsimisDe acuerdo a los registros proporcionados por las IPS de Bucaramanga en 2019, ingresaron 874 personas a estas instituciones, de las cuales se obtuvo información de la parte del cuerpo afectada de 665 personas, siendo las más frecuentes en su orden: miembros inferiores, miembros superiores, tórax y cabeza .Con relación a los costos, se obtuvo información de 812 personas lesionadas por siniestros de tránsito y se identificó una mediana de US$ 56,59  y un promedio de US$ 290,11 ± 731,22 .Se observaron diferencias en la distribución de algunas variables sociodemográficas entre los cuartiles. No se identificaron diferencias significativas entre los cuartiles en relación al género, sin embargo, en todos los cuartiles, el género masculino tiene porcentajes mayores al 83%. En cuanto a la edad, se identificaron diferencias significativas ; en el cuarto cuartil las personas menores de 18 años representan el 10,84% (22) y en los otros cuartiles representan porcentajes inferiores al 7%. Además, en el cuarto cuartil las personas de 46 a 60 años corresponden al 13,79% (28) y en los otros cuartiles los porcentajes son menores al 10,50%. De esta forma, los OR son significativos para estas dos categorías, en comparación con los mayores de 60 años .Referente a las variables relacionadas con el cumplimiento de normas, se identificó que quienes portan la licencia y seguro obligatorio representan un menor porcentaje en el Q4 que en los Q1-Q3. Los OR son protectores con intervalos de confianza que no atraviesan el valor de asociación nula. Por otra parte, la gravedad reportada por la Dirección de Tránsito Municipal considera que de quienes acudieron a las IPS de Bucaramanga el 92,24% (749) fueron clasificados como lesionados, el 1,60% (13) fallecieron y el 6,16% (50) sin gravedad, los OR e IC de estas dos últimas categorías son inferiores a 1.Respecto a la hipótesis del siniestro, no se identificaron diferencias estadísticamente significativas que afecten el costo en la comparación por cuartiles; sin embargo, cuando la hipótesis del siniestro fue embriaguez el OR fue de 12,44  .El tipo de vehículo involucrado en los pacientes que acuden a las IPS es principalmente la motocicleta, con porcentajes mayores al 83% en todos los cuartiles; además, en el Q4 sobresale, en segundo lugar, la bicicleta con el 7,88% (16). De esta forma, los OR identificados fueron 2,79  y 7,66  al comparar con los siniestros que involucran automóvil, respectivamente.Para la parte del cuerpo afectada, se aprecia que las lesiones en la cabeza tienen mayor proporción en el Q4 con el 33,33% (53), seguidamente las lesiones por miembros inferiores con el 20,13% (32). Si la parte del cuerpo afectada es la cabeza, el OR fue de 4,50  en comparación con la categoría que asume diferentes partes del cuerpo ., las partes del cuerpo más afectadas son la cabeza y las extremidades, el trauma craneoencefálico está asociado a la mortalidady entre los factores de riesgo se identifican el desacato a las normas de tránsitoy la imprudencia del conductor.Son pocos los estudios que informan las características y costos de las lesiones ocurridas por siniestros de tránsito. En Colombia, algunos estudios han descrito la incidencia, los factores asociados y las características de las lesiones ocurridas, y han reportado que los motociclistas son quienes más sufren lesiones.En nuestro estudio, los siniestros de tránsito se presentan más en hombres, jóvenes, con licencia de conducción al día, que en su mayoría manejaron con exceso de velocidad y desobedecieron las señales o normas de tránsito, hallazgos similares a lo reportado por otros autores. Sin embargo, cuando se consideran solo los datos de quienes acudieron a instituciones de salud, el principal vehículo involucrado fue la motocicleta, al igual que en otros estudios.En relación al tipo de vehículo involucrado, primero, se encontró el automóvil, seguido de la motocicleta.En cuanto a las lesiones presentadas, en nuestro estudio las principales partes afectadas fueron miembros superiores, miembros inferiores y cabeza, a diferencia del estudio en Brasil que identificó lesiones en la cabeza, sin embargo, en esta última se analizaron solo accidentes en moto, pero se debe tener en cuenta que en nuestro estudio no se incluyeron costos indirectos, costos por pérdida de productividad derivada del accidente que, según otros estudios, pueden ser más altos que los netamente relacionados a la atención en salud debido al accidente.Por otra parte, la mediana de costos por siniestro de tránsito fue de US$ 56  y el promedio 290,11 ± 731,22  correspondiente solo a los gastos médicos derivados de su permanencia en el hospital, podría considerarse como un costo bajo comparado con el estudio realizado en Irán donde el promedio del costo está en US$ 9,024.De esta manera, los costos derivados de los siniestros de tránsito pueden generar impacto socioeconómico a la comunidad, por ello la importancia de adoptar medidas de prevención encaminadas a reducir la ocurrencia de los mismos. Una de esas medidas puede ser la toma de acciones para mejorar la congestión vehicular, ya que algunos estudios han encontrado que volúmenes de tráfico alto pueden aumentar la probabilidad de accidentes debido a que hay más automóviles en la carretera. Sin embargo, hay que tener en cuenta que, en volúmenes de tráfico bajo, los accidentes también son frecuentes como resultado de altas velocidades; esto último sugiere intervenciones en regulaciones y controles de velocidad en las carreterasEn cuanto a este hallazgo es conveniente continuar explorando los efectos de la congestión vehicular en los accidentes de tránsito, dado que los resultados del presente estudio, como no respetar la prelación, adelantar invadiendo, adelantar por derecha y girar bruscamente, podrían suponer comportamientos derivados del afán o premura luego de pasar por un periodo de tráfico vehicular.. También, se observó relación estadísticamente significativa entre la gravedad de la lesión y el aumento de los costos similar a lo reportado en un estudio en Haití donde los pacientes lesionados en accidentes de carretera representaron el mayor costo con un valor promedio de US$ 1,220.En nuestro estudio se encontró una relación estadísticamente significativa de los costos por accidentes de tránsito con la edad, portar licencia y seguro al día, la gravedad del accidente según la clasificación realizada por la dirección de tránsito y la parte del cuerpo afectada, similar a lo reportado en estudio llevado a cabo en Irán. En Colombia, para el periodo 2008–2010 la Universidad de los Andes calculó el costo de los accidentes de tránsito alrededor del 1% del PIB, valor que contempla los costos médicos, humanos, administrativos y las pérdidas económicas por daños a la propiedad. En el 2016 se estimó en 1,52 billones de pesos anuales el costo de los accidentes de tránsito asumido por el Seguro Obligatorio de Accidentes de Tránsito y la Administradora de los Recursos del Sistema General de Seguridad Social en Salud.En Argentina, Brasil, Colombia y México, entre los años 2006 y 2015 se calculó en 13.540 millones de dólares la pérdida acumulativa del PIB causada por las enfermedades crónicas no transmisibles más frecuentes, cardiopatías, los accidentes cerebrovasculares y la diabetesdonde fue asumida como un factor en el que se presenta aumento de las secuelas y, por ende, de los costos por pérdida de capacidad de producción.A pesar que en nuestro estudio no se encontró relación estadísticamente significativa entre el género y los costos, sí se observó mayor número de accidentes en hombres, lo cual podría ser considerado como un factor de riesgo y enfoque de las medidas de prevención en esta población. Esta condición también se identificó en Brasil, como una manera de vigilar y estar reeducando a los conductores. Lo anterior permitiría reducir los gastos derivados de los accidentes de tránsito en el sistema de salud y en la comunidad que permitan derivar los recursos hacia la suplencia de otras necesidades básicas de la población y, así, probablemente reducirían la carga económica de la nación.Los resultados del estudio ponen de manifiesto la necesidad de centrar la prevención en los factores identificados con mayor frecuencia en este tipo de accidentes como el género masculino, la edad joven, la motocicleta como vehículo de transporte y la prevalencia de algunos comportamientos no adecuados en el momento de manejar, sin que esto se relacione con el tener la licencia y documentación de seguros en regla. De esta manera, se deben enfocar acciones educativas que generen una conciencia colectiva frente al cambio de comportamientos de riesgo para accidentarse. Es de resaltar que en varios países se están implementando una licencia de conducción por puntosPara el presente estudio se reconocen limitaciones como: no se obtuvo información de costos de atención de IPS de otros municipios del área metropolitana ; además, en la información reportada por las IPS respecto de la CIE-10, 209 registros no proporcionaban datos sobre la parte del cuerpo afectada específicamente y asignaron un CIE-10 referente al actor vial .; además, desglosar los costos de atención medica directa por profesionales, medicamentos, transporte, ayudas diagnósticas y dispositivos. Adicionalmente, vale la pena indagar respecto de la calidad de las motocicletas, de los elementos de protección personal y el uso adecuado de los mismos.También se debe tener en cuenta que los costos generados pueden ser inferiores, dado que los recursos humanos y tecnológicos para la atención en salud pueden ser menores que los de países desarrollados. De otra parte, sería interesante en estudios futuros vincular variables, como ingesta de alcohol, condiciones de las vías donde ocurrió el siniestro de tránsito, uso de elementos de proyección personal, y analizar los costos indirectos como la pérdida de la capacidad de producción por las secuelas dejadas por el accidente, de esta manera se podría brindar una proyección más amplia para las asignaciones presupuestales a estos eventos y las tarifas previstas por las aseguradoras para atender esta situación, tal como nos plantean otros estudiosFinalmente, se identificó que los factores relevantes de un aumento considerable de los costos en los accidentes de tránsito fueron la motocicleta, la bicicleta, ser menor de 18 años o tener entre los 46 y los 60 años, lesión en la cabeza y embriaguez como hipótesis. Contrariamente se encontró una disminución de los costos en los accidentes de tránsito en los casos que el conductor cumplía con la normatividad de portar licencia de conducción y póliza de seguro obligatorio de accidente. Es relevante identificar mecanismos para disminuir este tipo de eventos, siendo conocedores de que son prevenibles, se pueden implementar medidas para disminuir su severidad y, por ende, los costos y secuelas para la sociedad.


Porém, a ausência de ampla disponibilidade de laboratórios de cateterismo e problemas logísticos, principalmente relacionados ao transporte, limitam o acesso dos pacientes com IAMCSST a essa forma de tratamento.3 Isso é destacado na presente publicação, onde apenas 0,26% da população analisada era da vasta região Norte do Brasil, enquanto a maioria (58%) era da região Sudeste. Talvez mais importante seja o fato de que a utilização de terapias de reperfusão (fibrinolíticos ou ICPP) em geral está longe do ideal no Brasil, e importantes diferenças regionais têm sido observadas.5 É importante ressaltar que a metanálise anteriormente citada de Fazel et al.,3 encontrou odds ratios de 0,79, 0,53, 0,70 e 1,19 para morte por todas as causas, reinfarto, acidente vascular cerebral e sangramento grave, respectivamente, ao comparar o tratamento farmacoinvasivo e a abordagem com tratamento fibrinolítico, que pode ser uma opção para problemas relacionados ao acesso à ICPP.A ICPP é o método preferido de reperfusão para pacientes com IAMCSST que se apresentam dentro de 12 horas de evolução do início dos sintomas.1 e a literatura resumida na Tabela 3 deve ser interpretada com cautela. Primeiro, o artigo brasileiro analisou apenas a fase intra-hospitalar, enquanto os demais analisaram períodos de seguimento que variaram de 30 dias a 1 ano. Segundo, nem todos os estudos estavam relacionados a pacientes submetidos à ICPP. Por exemplo, o “DynTIMI”6 foi derivado do estudo ExTRACT, que testou o papel da enoxaparina versus heparina não fracionada em pacientes com IAMCSST, e o GRACE7 foi um registro internacional com uma ampla população de pacientes com síndromes coronárias agudas (com ou sem supradesnível do segmento ST). Vale ressaltar que todos os estudos incluídos na Tabela 3 desenvolveram escores de risco para facilitar a compreensão e facilitar a utilização dos resultados na prática diária, o que não foi o caso da publicação de Castro et al.1 Os autores perderam uma excelente oportunidade para desenvolver um escore de risco baseado em uma população brasileira, assim como fizeram algumas publicações anteriores do Brasil.8A comparação entre o artigo de Castro et al.1 afirmaram que o único fator de risco da Central Nacional de Intervenções Cardiovasculares (CENIC) que não estava de acordo com as demais publicações era o sexo feminino. O papel do sexo feminino como fator de risco prognóstico no IAMCSST é motivo de discussão há décadas, com alguns estudos, como o presente, concluindo que o sexo feminino é um fator de risco independente para pior prognóstico, e outros concluindo o contrário.9 Talvez a melhor explicação seja aquela fornecida na publicação clássica de Vacarinno et al.,10 há muitos anos, a saber, que existe uma interação entre sexo, idade e mortalidade por infarto do miocárdio, onde mulheres mais jovens, mas não mulheres mais velhas, apresentam maiores taxas de óbito hospitalar do que homens da mesma idade;10 no entanto, publicação recente sugeriu que outras interações também podem ser importantes.11 Em uma análise mais detalhada, podemos notar que existem muitas outras diferenças entre o estudo brasileiro e os demais. Por exemplo, o escore de risco CADILLAC incluiu 7 variáveis, incluindo anemia e insuficiência renal,12 e o escore ALPHA teve apenas 5 variáveis, incluindo frequência cardíaca, necessidade de suporte de vida e acesso arterial, atingindo uma estatística c impressionante de 0,88 para mortalidade por todas as causas em 30 dias.13De maneira um tanto simplificada, Castro et al.,1 contribui para uma melhor compreensão da epidemiologia do IAMCSST no Brasil, com um número robusto de aproximadamente 27.000 pacientes analisados. Sua principal limitação é provavelmente um potencial viés de inclusão, uma vez que a contribuição dos pesquisadores foi espontânea e, talvez mais importante, foi perdida a oportunidade de se desenvolver e validar um escore brasileiro para pacientes com IAMCSST submetidos à ICPP.Em resumo, o estudo de Castro et al., 1 should be commended for providing the scientific community with a useful publication analyzing predictors of all-cause mortality in patients with ST-elevation acute myocardial infarction (STEMI) who are submitted to primary percutaneous coronary intervention (PPCI).Castro et al.2 To the best of my knowledge, the most recent meta-analysis comparing fibrinolytic therapy with PPCI found odds ratios of 0.73 (p = 0.002), 0.38 (p < 0.001), 0.38 (p < 0.001), and 1.03 (p = 0.86) for all-cause death, reinfarction, stroke, and major bleeding, respectively. However, absence of widespread availability of catheterization laboratories and logistical problems, mainly related to transportation, limit the access of patients with STEMI to this form of treatment.3 This is highlighted in the present publication, where only 0.26% of the analyzed population was from the vast North Region of Brazil, whereas the majority (58%) was from the Southeast Region. Maybe more importantly, the utilization of reperfusion therapies (fibrinolytics or PPCI) in general is far from ideal in Brazil, and important regional differences have been observed.5 Importantly, the previously cited meta-analysis by Fazel et al.3 found odds ratios of 0.79, 0.53, 0.70, and 1.19 for all-cause deaths, reinfarction, stroke, and major bleeding, respectively, when comparing the pharmacoinvasive approach with fibrinolytic treatment, which can be an option for issues related to access to PPCI.PPCI is the preferred method of reperfusion for patients with STEMI presenting within 12 hours of evolution from onset of symptoms.1 and the literature summarized in Table 3 must be interpreted carefully. First, the Brazilian paper analyzed only the in-hospital phase, while the others analyzed follow-ups ranging from 30 days to 1 year. Second, not all studiesThe comparison between the paper by Castro et al.6 was derived from the ExTRACT study, which tested the role of enoxaparin versus non-fractioned heparin in patients with STEMI, and the GRACE7 was an international registry with a broad population of patients with acute coronary syndromes (with or without ST-elevation). It is noteworthy that all the studies included in Table 3 developed risk scores to facilitate understanding and to increase the utilization of the results in daily practice, which was not the case of the publication by Castro et al.1 The authors missed an excellent opportunity to develop a risk score based on a Brazilian population, as did some previous publications from Brazil.8were related to patients submitted to PPCI. For example, the “DynTIMI”1 stated that the only risk factor from the National Registry of Cardiovascular Interventions  not in agreement with the other publications was female sex. The role of female sex as a prognostic risk factor in STEMI has been a matter of discussion for decades, with some studies, such as the present one, concluding that female sex is an independent risk factor for worse prognosis and others concluding that it is not.9 The best explanation was, perhaps, the one provided in the classical publication by Vacarinno et al.10 many years ago, namely, that there is an interaction between sex, age, and mortality in myocardial infarction with younger women, but not older women, having higher rates of in-hospital deaths than men of the same age;10 however, a more recent publication suggested that other interactions may be important as well.11 In a more detailed analysis, we can note that there are many other differences between the Brazilian study and the others. For example, the CADILLAC risk score included 7 variables, including anemia and renal insufficiency,12 and the ALPHA score had only 5 variables, including heart rate, need for life support, and arterial access, reaching an impressive c-statistic of 0.88 for all-cause mortality at 30 days.13In a somewhat simplistic manner, Castro et al.1 contributes to a better understanding of the epidemiology of STEMI in Brazil, with a robust number of approximately 27,000 patients analyzed. Its main limitation is likely a potential inclusion bias, since the contribution of the investigators was spontaneous, and, maybe more importantly, an opportunity to develop and validate a Brazilian score for patients with STEMI submitted to PPCI was missed.In summary, the study by Castro et al.


Encontram-se comorbidades em mais da metade de idosos, com consequente necessidade de cuidados prolongados de profissionais da saúde, o que aumenta a probabilidade de aquisição da EI.16 O diagnóstico de EI em idosos, frequentemente, é atrasado ou esquecido.3 As manifestações podem ser inespecíficas, atribuídas ao envelhecimento e outras condições. A febre pode estar ausente, havendo apenas confusão mental.17 A EI pode se apresentar com complicações semelhantes a outras condições, como insuficiência cardíaca (IC), acidente vascular encefálico (AVE) ou embolia sistêmica atribuível a fibrilação atrial.16 No Brasil, apesar de uma população idosa crescente, até o momento não foi publicado nenhum artigo publicado a respeito de EI para esse grupo. O objetivo deste estudo é descrever o grupo de idosos em nossa coorte de EI em adultos e compará-los aos não idosos, ressaltando as diferenças entre os grupos.A endocardite infecciosa (EI) é uma doença grave, com mortalidade intra-hospitalar média de 20%.in loco . O estudo é retrospectivo de pacientes idosos definidos como pelo Estatuto do Idoso do Brasil,18 identificados na coorte de pacientes adultos com critério de EI definitiva pelos critérios modificados de Duke e conduzido pelo período de janeiro de 2006 a dezembro de 2019. As variáveis do estudo foram as incluídas em ficha de coleta de dados padrão ( case report form ) descritas previamente.4 A análise estatística foi realizada utilizando-se o programa Jamovi®, versão 1.2.2. Os dados foram expressos como frequências, médias ± desvio-padrão da média, mediana e intervalo interquartil. Para a análise bivariada, foram usados os testes do Qui-quadrado e Exato de Fisher. Para verificar a normalidade da distribuição, utilizou-se o teste de Shapiro-Wilk. Os testes t de Student não pareado e o de Mann-Whitney foram utilizados para comparar as variáveis numéricas entre os grupos de interesse. O valor de p < 0,05 foi considerado estatisticamente significante.O local do estudo é um hospital público terciário especializado em cardiologia de alta complexidade, com cirurgia cardíaca S. aureus isolados, 10  eram MRSA e, desses, 6 eram hospitalares e 4 comunitários. Hemoculturas foram negativas em 27,8%  no período. A idade média foi 68,8±6,3 anos; sexo masculino correspondeu a 73 casos . A apresentação foi aguda, isto é, sinais e sintomas foram observados em menos de 1 mês de evolução, em 60% dos casos (57/95) e subaguda em 40% (38/95). A aquisição foi comunitária em 49 , nosocomial em 37  e relacionada a saúde não nosocomial em 11 . Microrganismos mais prevalentes foram enterococos 18 . Entre 12 m 27,8%   . Ecocarm 27,8%   ; cirurgDos 80 idosos com indicação cirúrgica , 59  foram operados. A mortalidade hospitalar foi de 38 ; 22/59 (37%) morreram entre os que foram abordados cirurgicamente e 16/38 (42%) entre os que não foram.Realizou-se uma análise comparativa utilizando dados de 359 pacientes adultos com EI de janeiro de 2006 a setembro de 2019   . Um totviridans em menor e frequência de S. aureus semelhante.Quanto à clínica, pacientes idosos tiveram menos febre, sopro regurgitante novo, eventos embólicos, incluindo eventos para o sistema nervoso central, e menos esplenomegalia. Quanto a etiologia, idosos apresentaram enterococos com maior frequência, a estreptococos do grupo versus 63,4% de NI . Outras indicações cirúrgicas foram abscesso miocárdico/paravalvar em 21,5% de idosos versus 20% de NI ; deiscência de prótese  e bacteremia persistente em 9% versus 4% de NI . A mortalidade foi mais que duas vezes maior em pacientes idosos .4 Ratifica-se que a população idosa continua sendo mais exposta a procedimentos diagnósticos/terapêuticos, havendo maior predisposição à EI em função de eventos de bacteremia ocorridos nestes cenários e a presença de material sintético/dispositivos.Comorbidades foram mais prevalentes entre idosos, como esperado; tal fator é semelhante em estudo multicêntrico com grande número de pacientes, em que as frequências entre idosos e não idosos, respectivamente, de DM de 22,9% x 11,9% , de câncer geniturinário, de 4,7% x 0,6%  e de câncer do trato gastrintestinal de 3,2% x 0,8% .19 Na Observou-se maior frequência de EI hospitalar entre nossos idosos ; proporção semelhante é notada na literatura, em que a aquisição nosocomial representa 10,2% a 37% dos casos de EI em idosos.viridans  e S. aureus . Ainda que estreptococos orais tenham sido anteriormente responsáveis pela maioria dos casos de EI em idosos, estafilococos predominam nas últimas décadas, especialmente S. aureus .9 Enterococos também estão relacionados a bacteremia por acessos vasculares, tendência epidemiológica que está ligada ao aumento da incidência de EI associada a cuidados de saúde.12 A frequência de EI causada por estreptococos que colonizam o trato digestivo, como Streptococcus gallolyticus e enterococos, acontece por conta da maior incidência de lesões do cólon em pacientes idosos.19 Todos os 7 pacientes com EI por grupo bovis tiveram o TGI investigado, mas não aqueles com EI por enterococos.Microrganismos mais prevalentes e observados em nossa série foram enterococos , estreptococos do grupo 6 Motivos pelos quais idosos que tiveram indicação cirúrgica não foram operados dizem respeito, sobretudo, ao status pré-operatório crítico, como observado pela elevada frequência de ventilação mecânica e uso de inotrópicos no pré-operatório. É importante notar que aneurismas micóticos e insuficiência renal aguda não foram mais frequentes entre idosos e NI, e que eventos de SNC foram menos frequentes em idosos. Em alguns estudos, a idade avançada é um preditor independente de mortalidade intra-hospitalar,12 o que influencia negativamente na decisão pelo procedimento. Contudo, em estudo recente realizado na China, notou-se que a sobrevida em 1 ano dos idosos que foram submetidos à abordagem cirúrgica foi maior do que nos indivíduos submetidos à terapêutica medicamentosa isoladamente .11 Além disso, mesmo entre os octogenários,6 os pacientes operados apresentam melhor sobrevida em 1 ano  e em 3 anos , respectivamente.Em nosso centro de referencia em cirurgia cardíaca, houve indicação de troca valvar em mais de 4/5 dos idosos; porém, mais de 1/4 deles não foram operados. Tal fato possui aspecto multifatorial, incluindo idade avançada, múltiplas comorbidades, fragilidade, risco cirúrgico elevado e não aceitação de cirurgia pelo paciente ou sua família, entre outros, como observado através de estudo em EI em octogenários.20 Por fim, notamos que:A mortalidade entre idosos em nosso estudo foi de 39,1%; na literatura, a taxa de óbitos variou de 16% a 43,2%.Proporção expressiva (um quarto) das EI ocorreu em idosos, mesmo no sistema de saúde pública no Brasil;Enterococos foi o patógeno mais frequente, e houve elevada proporção de MRSA entre a etiologia estafilocócica, o que sugere aquisição nosocomial ou foco gastrintestinal/geniturinário;A clínica é menos exuberante em idosos, com menos febre, sopro novo e eventos embólicos;A mortalidade nos idosos foi alta, o que sugere a contribuição da idade e das comorbidades, e possivelmente de diagnóstico tardio e não realização de cirurgia cardíaca. 3 It has shown an increasing incidence, and the rise in its prevalence among the elderly population deserves to be highlighted.9 In elderly patients with IE, there are differences regarding the clinical presentation, complications, presence of comorbidities, therapeutic approach and mortality.13 IE guidelines do not specifically address the elderly population and it is not clear to what extent they can be appropriately used in these patients.15 The elderly population has clearly benefited from medical progress, with diagnostic-therapeutic techniques that influence the increase in life expectancy and less invasive procedures.10 One example is the transcatheter aortic valve implantation in the management of aortic valve diseases.15 However, these procedures, together with the increasing implantation of cardiovascular electronic devices (CED) contribute to infections such as IE. Comorbidities are found in more than half of the elderly, with the consequent need for long-term care from health professionals, which increases the probability of acquiring IE.16 The diagnosis of IE in the elderly is often delayed or forgotten.3 Manifestations may be nonspecific, attributed to aging and other conditions. Fever may be absent, with the presence of mental confusion only.17 IE can present with complications similar to those of other conditions, such as heart failure (HF), cerebrovascular accident (CVA) or systemic embolism attributable to atrial fibrillation.16 In Brazil, despite a growing elderly population, to date there is no published article about IE in this group. The aim of our study was to describe the elderly group in our adult IE cohort and compare them with non-elderly individuals, highlighting the differences between the groups.Infectious endocarditis (IE) is a serious disease with a mean in-hospital mortality of 20%.18 identified in the cohort of adult patients with definitive IE, according to the modified Duke criteria, conducted from January 2006 to December 2019. The study variables were included in the previously described data collection form (case report form).4 The statistical analysis was performed using the Jamovi software, version 1.2.2. Data were expressed as frequencies, means ± standard deviation of the mean, median and interquartile range. For the bivariate analysis, Chi-square and Fisher’s exact tests were used. The Shapiro-Wilk test was used to verify the normality of the distribution. The unpaired Student’s t test and the Mann-Whitney test were used to compare numerical variables between the groups of interest. A value of p<0.05 was considered statistically significant.The study site is a tertiary, public, high-complexity cardiology hospital with on-site cardiac surgery. This is a retrospective study of elderly patients, as defined by the Statute of the Elderly of Brazil,enterococci 18 (25.7%). Of the 12 isolated S. aureus cases, 10 (83.3%) were MRSA and of these, 6 were hospital and 4 community-acquired cases. Blood cultures were negative in 27.8% ( Elderly patients accounted for 97 of 370 (26.2%) cases of IE in the period. The mean age was 68.8±6.3 years; the male gender corresponded to 73 cases (75.2%). The presentation was acute, i.e., signs and symptoms were observed in less than one month of evolution, in 60% (57/95) of the cases and subacute in 40% (38/95). The disease was community acquired in 49 (50.5%), nosocomial in 37 (38.1%) and related to non-nosocomial health care in 11 (11.3%). The most prevalent microorganisms were n 27.8%   . Transen 27.8%   ; previoOf the 80 (82.4%) elderly with surgical indication, 59 (73.7%) were submitted to surgery. Hospital mortality was 38 (39.1%); 22/59 (37%) died among those who were submitted to surgery and 16/38 (42%) among those who were not.A comparative analysis was performed using data from 359 adult patients with IE from January 2006 to September 2019   . A totaenterococci more frequently, streptococci from the Viridans group less frequently, and similar frequency of S. aureus . Elderly individuals had a greater need for mechanical ventilation and inotropic agent use before the surgery. There was no difference regarding acute kidney injury, conduction disorders, recurrent embolization and abscesses. There was no difference regarding the proportion of surgical indications between the elderly and non-elderly (NE). Elderly individuals had surgical indication in 81.7% of the cases and 66.3% were submitted to surgery; in comparison, of the 88.7% of NE patients for whom surgery was indicated, 84% were operated. The indication was heart failure failure secondary to acute mitral or aortic regurgitation in 56.5% of the elderly vs. 63.4% of NE (p=0.243). Other surgical indications were myocardial/paravalvular abscess in 21.5% of elderly vs. 20% of NE (p=0.757); prosthesis dehiscence  and persistent bacteremia in 9% vs. 4% of NE (p=0.062). Mortality was more than twice as high in elderly patients .4 It has been confirmed that the elderly population continues to be more exposed to diagnostic/therapeutic procedures, with a greater predisposition to IE due to bacteremic events that occurred in these scenarios and the presence of synthetic material/devices.Comorbidities were more prevalent among the elderly, as expected; this is similar to a multicenter study with a large number of patients, with the frequencies in the elderly and non-elderly, of DM being 22.9% vs. 11.9% (p<0.001); of genitourinary cancer, being 4.7%, respectively, vs. 0.6% (p<0.001) and 3.2% vs. 0.8% of gastrointestinal tract cancer (p<0.001).19A higher frequency of in-hospital IE was observed, which represented 39.8% among our elderly patients; a similar proportion has been observed in the literature, in which hospital-acquired disease represents 10.2 to 37% of IE cases in the elderly.enterococci (25.7%), streptococci from the Viridans group (17.1%) and S. aureus (17.1%). Although oral streptococci have been previously responsible for most cases of IE in the elderly, staphylococci have predominated in recent decades, especially S. aureus.9Enterococci are also related to bacteremia caused by vascular access. This epidemiological trend is linked to the increased incidence of IE associated with healthcare.12 The frequency of IE caused by streptococci that colonize the digestive tract, such as Streptococcus gallolyticus and enterococci , is also higher due to the higher incidence of colon lesions in elderly patients;19 all 7 patients with IE caused by the bovis group had their GIT investigated, but not those with IE caused by enterococci .The most prevalent microorganisms observed in our series were 6 In our study, the reasons why elderly individuals who had surgical indication were not submitted to the surgical procedure are mainly related to their critical preoperative status, as noted by the high frequency of mechanical ventilation and the use of inotropic agents in the preoperative period. It is noteworthy that events such as mycotic aneurysms and acute kidney injury were not more frequent among the elderly compared to the NE, and that CNS events were less frequent in the elderly. In some studies, older age is an independent predictor of in-hospital mortality,12 which negatively influences the decision to perform the procedure. However, in a study carried out recently in China, it was observed that the one-year survival among the elderly submitted to surgical procedures was greater than that of those who underwent drug therapy alone .11 Moreover, even among octogenarians,6 those submitted to the surgical procedure showed better one-year (93.6%) and three-year (75.0%) survival, respectively. Mortality among the elderly in our study was 39.1%; in the literature, the mortality varies from 16% to 43.2%.20In our referral center for heart surgery, valve replacement was indicated in more than 4/5 of the elderly, but more than 1/4 of them were not submitted to surgery. This fact has a multifactorial aspect, including older age, multiple comorbidities, frailty, high surgical risk, non-acceptance of surgery by the patient or their family, among others, as observed in a study on IE in octogenarians.enterococci were the most frequent pathogens, and there was a high proportion of MRSA in the staphylococcal etiology, suggesting nosocomial acquisition or gastrointestinal/genitourinary focus, iii) the clinical picture is less exuberant in the elderly, with less fever, new murmur and embolic events and iii) mortality in the elderly was high, suggesting the contribution of age and comorbidities, and possibly a late diagnosis and not undergoing cardiac surgery.As conclusions, we observed that i) a significant proportion (one quarter) of IE occurred in the elderly, even in the public health system in Brazil ii)


In the published article, there were errors regarding the affiliations for Anke Paula Ingrid Kleinert-Altamirano, Earnest James Paul Daniel, and Miao He.Anke Paula Ingrid Kleinert-Altamirano should have affiliations 5 “Centro de Rehabilitación e Inclusión Infantil Teletón, Tuxtla Gutiérrez, Mexico” and 7 “Hospital Regional de Alta Especialidad Ciudad Salud, Tapachula, Mexico” instead of 5 and 6.Miao He and Earnest James Paul Daniel should have affiliation 6 “Palmieri Metabolic Disease Laboratory, Children’s Hospital of Philadelphia, Philadelphia, PA, United States” instead of 7.The authors apologize for these errors and state that this does not change the scientific conclusions of the article in any way. The original article has been updated.