Cardiac Rehabilitation Effectiveness for Coronary Artery Disease by Clinical Era: Trial Sequential Analysis

Cardiac rehabilitation (CR) is an outpatient model of care for the secondary prevention of cardiovascular disease, which is widely and strongly recommended in international clinical guidelines. The latest update of the Cochrane systematic review on CR for patients with coronary artery disease1 found that CR is effective in preventing cardiovascular death and hospital admissions, but not all-cause mortality, reinfarctions and other complications, as reported in the previous update. This could be due to the inclusion of more recent trials. Thanks to advances in medicine, patients now have access to acute revascularization treatments such as thrombolysis and angioplasty, and therefore achieve better outcomes, such that some have hypothesized that CR may have less impact in the current clinical era2. Although the Cochrane review included a meta-regression which showed no impact of the publication year on the effectiveness,1 some others meta-analyses in the field that have included only recent trials,2,3 have contradicted this finding. In this context, we conducted a secondary analysis of these trials with the aim of examining whether there is sufficient data to determine effectiveness of CR on all-cause and cardiovascular mortality as well as hospitalization, and to test effectiveness over time, using trial sequential analysis (TSA) for the first time. With sequential analysis, it is possible to determine the need for more trials or whether the results are conclusive.4 Such analysis allows the effect to be observed as the participants in the primary studies accumulate even if the optimal sample size has not been reached, adjusting the threshold of statistical significance as the sample size is accumulated. 5This work was supported by the National Agency for Research and Development (ANID), Chile [FONDECYT Regular 2018, grant number 1181734

Effectiveness of bioceramics in the maintenance of pulp vitality in direct pulp covering in primary and permanent dentition: systematic review with meta-analysis

Introducción: Se han desarrollado materiales bioactivos para el recubrimiento pulpar directo con el objetivo de preservar la pulpa dentaria y mantener el diente por mayor tiempo en la cavidad oral. Objetivo: El objetivo de esta revisión fue evaluar la efectividad del uso de bioceramicos como material de recubrimiento directo pulpar para mantener la vitalidad pulpar en dientes primarios y permanentes con pulpitis reversible. Metodología: Se realizó una revisión sistemática con meta análisis. Se estudió el éxito en el tratamiento del mantenimiento de la vitalidad, el dolor postoperatorio y la decoloración. Se realizó una búsqueda Electrónica en las bases de datos: MEDLINE, EMBASE, COCHRANE, SCOPUS, LILACS, BBO. Se extrajeron los datos y se analizaron con Rev Man. Resultados: Se incluyeron ensayos clínicos aleatorizados en la cual se realizaron recubrimiento pulpar directo con silicatos tricalcicos comparado con otros materiales de recubrimiento. Comparando tres biocerámicos no se encontraron diferencias significativas en el mantenimiento de la vitalidad pulpar. En cuanto a la decoloración se observaron diferencias estadísticamente significativas a favor de Biodentine (p <0,001).  Discusión: la relevancia clínica de estos hallazgos es discutible debido a su pequeña magnitud general y al alto riesgo de sesgo de los estudios incluidos.Introduction: Bioactive materials have been developed for direct pulp capping in order to preserve the dental pulp and keep the tooth longer in the oral cavity. Objective: The objective of this review was to evaluate the effectiveness of the use of bioceramics as direct pulp capping material to maintain pulp vitality in primary and permanent teeth with reversible pulpitis. Methods: A systematic review with meta-analysis was performed. Success in treating vitality maintenance, postoperative pain, and discoloration was studied. An electronic search was carried out in the databases: MEDLINE, EMBASE, COCHRANE, SCOPUS, LILACS, BBO. Data were extracted and analyzed with Rev Man. Results: Randomized clinical trials in which direct pulp capping with tricalcium silicates was performed compared with other capping materials were included. Comparing three bioceramics, no significant differences were found in the maintenance of pulp vitality. Regarding discoloration, statistically significant differences were observed in favor of Biodentine (p <0.001). Discussion: the clinical relevance of these findings is debatable due to their small overall magnitude and the high risk of bias of the included studies

Developing a Complex Understanding of Physical Activity in Cardiometabolic Disease from Low-to-Middle-Income Countries—A Qualitative Systematic Review with Meta-Synthesis

From MDPI via Jisc Publications RouterHistory: accepted 2021-11-06, pub-electronic 2021-11-15Publication status: PublishedPhysical activity behaviour is complex, particularly in low-resource settings, while existing behavioural models of physical activity behaviour are often linear and deterministic. The objective of this review was to (i) synthesise the wide scope of factors that affect physical activity and thereby (ii) underpin the complexity of physical activity in low-resource settings through a qualitative meta-synthesis of studies conducted among patients with cardiometabolic disease living in low-to-middle income countries (LMIC). A total of 41 studies were included from 1200 unique citations (up to 15 March 2021). Using a hybrid form of content analysis, unique factors (n = 208) that inform physical activity were identified, and, through qualitative meta-synthesis, these codes were aggregated into categories (n = 61) and synthesised findings (n = 26). An additional five findings were added through deliberation within the review team. Collectively, the 31 synthesised findings highlight the complexity of physical activity behaviour, and the connectedness between person, social context, healthcare system, and built and natural environment. Existing behavioural and ecological models are inadequate in fully understanding physical activity participation in patients with cardiometabolic disease living in LMIC. Future research, building on complexity science and systems thinking, is needed to identify key mechanisms of action applicable to the local context

Variations in the financial impact of the COVID-19 pandemic across 5 continents: A cross-sectional, individual level analysis.

BACKGROUND: COVID-19 has caused profound socio-economic changes worldwide. However, internationally comparative data regarding the financial impact on individuals is sparse. Therefore, we conducted a survey of the financial impact of the pandemic on individuals, using an international cohort that has been well-characterized prior to the pandemic. METHODS: Between August 2020 and September 2021, we surveyed 24,506 community-dwelling participants from the Prospective Urban-Rural Epidemiology (PURE) study across high (HIC), upper middle (UMIC)-and lower middle (LMIC)-income countries. We collected information regarding the impact of the pandemic on their self-reported personal finances and sources of income. FINDINGS: Overall, 32.4% of participants had suffered an adverse financial impact, defined as job loss, inability to meet financial obligations or essential needs, or using savings to meet financial obligations. 8.4% of participants had lost a job (temporarily or permanently); 14.6% of participants were unable to meet financial obligations or essential needs at the time of the survey and 16.3% were using their savings to meet financial obligations. Participants with a post-secondary education were least likely to be adversely impacted (19.6%), compared with 33.4% of those with secondary education and 33.5% of those with pre-secondary education. Similarly, those in the highest wealth tertile were least likely to be financially impacted (26.7%), compared with 32.5% in the middle tertile and 30.4% in the bottom tertile participants. Compared with HICs, financial impact was greater in UMIC [odds ratio of 2.09 (1.88-2.33)] and greatest in LMIC [odds ratio of 16.88 (14.69-19.39)]. HIC participants with the lowest educational attainment suffered less financial impact (15.1% of participants affected) than those with the highest education in UMIC (22.0% of participants affected). Similarly, participants with the lowest education in UMIC experienced less financial impact (28.3%) than those with the highest education in LMIC (45.9%). A similar gradient was seen across country income categories when compared by pre-pandemic wealth status. INTERPRETATION: The financial impact of the pandemic differs more between HIC, UMIC, and LMIC than between socio-economic categories within a country income level. The most disadvantaged socio-economic subgroups in HIC had a lower financial impact from the pandemic than the most advantaged subgroup in UMIC, with a similar disparity seen between UMIC and LMIC. Continued high levels of infection will exacerbate financial inequity between countries and hinder progress towards the sustainable development goals, emphasising the importance of effective measures to control COVID-19 and, especially, ensuring high vaccine coverage in all countries. FUNDING: Funding for this study was provided by the Canadian Institutes of Health Research and the International Development Research Centre

Actividad física y ejercicio en la enfermedad cardiovascular

Antecedentes: la enfermedad cardiovascular es una de las principales causas de morbimortalidad en el mundo. Dentro de los factores de riesgo relacionados con el estilo de vida está la inactividad física, conducta frecuente en la población de todas las regiones. La actividad física y el ejercicio se constituyen en una potencial herramienta para la prevención, tratamiento y rehabilitación de los problemas cardiovasculares, existiendo evidencia de distinto nivel que la respalda. A pesar de ello, existen algunos vacíos de información en ésta área. Objetivo: Determinar el efecto de la actividad física y ejercicio en las distintas etapas del proceso salud-enfermedad de las enfermedades cardiovasculares. Métodos: Se realizaron tres trabajos de investigación. Un estudio de corte transversal, que permitió estimar la prevalencia de inactividad física en una población de la ciudad de Temuco en Chile, y dos revisiones sistemáticas: una revisión sistemática Cochrane de ensayos clínicos aleatorizados sobre el efecto del ejercicio en personar con riesgo cardiovascular total alto o incrementado y otra revisión sobre la calidad de las guías de práctica clínica en rehabilitación cardíaca basada en ejercicios a través de la utilización del instrumento AGREE II. Resultados: Un 18,37% de la población de Temuco, en Chile tiene un nivel de actividad física bajo. Las mujeres y las personas de niveles socioeconómicos medios tienen prevalencias más altas de actividad física insuficiente. La revisión sistemática sobre el efecto del ejercicio en personas de alto o incrementado riesgo cardiovascular incluyó 4 ensayos clínicos de baja calidad metodológica que fueron insuficientes para determinar la efectividad del ejercicio en este grupo de personas. La otra revisión incluyó nueve guías clínicas exclusivas de rehabilitación cardíaca con puntuaciones medias que fluctuaron desde el 48,92% en el dominio de aplicabilidad del AGREE II, hasta un 79,84% en el dominio de alcance y propósito. Conclusiones. (1) Los niveles de actividad física bajos son frecuentes en la población de Chile, similar a lo observado en otras poblaciones del mundo. (2) La efectividad del ejercicio en personas con incrementado o alto riesgo cardiovascular es incierta, siendo necesario desarrollar ensayos clínicos con el menor riesgo de sesgos posible. (3) La calidad de las guías clínicas en rehabilitación cardíaca es de moderada a alta.Background: cardiovascular diseases are one of the main causes of morbidity and mortality around the world. Among the life-style related risk factors is physical inactivity, a prevalent behaviour in all regions. Physical activity and exercise constitute a potential tool for prevention, treatment and rehabilitation of cardiovascular conditions, with it being supported by evidence of different levels. Despite this fact, information gaps continue to exist in this area. Objective: To determine the effect of physical activity and exercise on the different stages of the health-disease process of cardiovascular diseases. Methods: We conducted three research works. A cross-sectional study that allowed us to estimate the prevalence of physical inactivity in a population of the city of Temuco, Chile. And two systematic reviews: a Cochrane systematic review of randomised clinical trials about exercise effects on people with a high or increased total cardiovascular risk, and another review about the quality of the clinical practice guidelines on exercise-based cardiac rehabilitation, with the use of the AGREE II instrument. Results: A proportion of 18.37% of the population of Temuco (Chile) has a low level of physical activity. Women and people in the middle socioeconomic level have higher prevalence of insufficient physical activity. The systematic review about exercise effects on people with a high or increased cardiovascular risk included four clinical trials of low methodological quality that were insufficient to determine the effectiveness of exercise in this group of people. The other review included nine clinical guidelines exclusively about cardiac rehabilitation with mean scores fluctuating from 48.92% in the applicability domain of AGREE II to 79.84% in the domain of scope and purpose. Conclusion: (1) Low physical activity levels are prevalent in the population of Chile, similar to those observed in other populations of the world. (2) The effectiveness of exercise in people with high or increased cardiovascular risk remains uncertain; therefore, it is necessary to develop clinical trials with the lowest risk of bias as possible. (3) The quality of the clinical guidelines on cardiac rehabilitation is moderate to high

Is there evidence showing that salt intake reduction reduces cardiovascular morbidity and mortality risk?

A recent systematic review of Cochrane collaboration about the effect of reducing dietary salt concluded that “there is still insufficient power to exclude clinically important effects of reduced dietary salt on mortality or cardiovascular morbidity in normotensive or hypertensive populations”. This conclusion has generated an important debate, because the estimation that salt reduction can prevent 24% of strokes and 18% of myocardial infarctions has decided the health authorities of several nations to implement salt consumption reduction programs. The review of ecological studies and clinical trials allow to conclude that a reduction in salt consumption reduces blood pressure and methodological well conducted cohort studies has shown that cardiovascular events risk decreases progressively with lower levels of blood pressure. Combining this two finding we can assume that population should benefice from a decrease on salt consumption although there are no studies that shown a reduction in cardiovascular events in population with high sodium intake when dietary salt is reduced

Evolución del riesgo cardiovascular y sus factores en Temuco entre 1989 y 2011-12

Background: A successful cardiovascular prevention program should induce a reduction of risk factors along time. Aim: To assess changes in cardiovascular risk factors among males aged between 35 and 65 years living in Southern Chile. Material and Methods: The results of two cross sectional household surveys, with a probability sampling stratified by socioeconomic status, were analyzed. Two hundred males were evaluated in 1989 and 800 in 2011-12, paired by age for selection. Results: In the second survey, a mean weight increase of 4.5 kg was recorded. Body mass index increased from 27.1 to 28.6 kg/m² (p < 0.01), especially in men younger than 45 years old. No changes in smoking prevalence were observed. The prevalence of hypertension and hypertensive patients in treatment increased from 32.7 to 38.1% and from 17 to 33%, respectively. The number of treated hypertensive patients with a well-controlled blood pressure did not change significantly. In 1989 and 2011-12, mean total cholesterol values were 192 and 201 mg/dl respectively (p < 0.01). The figures for mean non-HDL cholesterol were 152 and 160 mg/dl (p = 0.03). The frequency of people with total cholesterol over 240 mg/dl or using statins increased from 15 to 25% (p < 0.01). The estimated 10 years risk of myocardial infarction and coronary death using Framingham tables was 9,0 in both periods (p = 0.95). Conclusions: In a 22 years period an increase in the prevalence of obesity and elevated total cholesterol was observed. There was a higher proportion of individuals treated for hypertension and dyslipidemia, but without reduction in the estimated cardiovascular risk

Validez predictiva del Ages and Stages Questionnaire (ASQ®), un cuestionario de cribado del desarrollo psicomotor infantil basado en el reporte de padres o cuidadores principales

Antecedents: els qüestionaris de cribratge del desenvolupament basats en l'informe de pares o cuidadors (CCDRP) han guanyat cada vegada major difusió. D'aquests, el més conegut a nivell mundial és l'Ages and Stages Questionnaire (ASQ), instrument que s'ha utilitzat a Catalunya i validat a Xile, i hi ha una bretxa quant al coneixement de la seva capacitat predictiva a més llarg termini. Objectiu: Determinar la confiabilitat i validesa predictiva del ASQ pel cribratge de dificultats en el desenvolupament. Mètodes: Es van realitzar tres treballs d'investigació. Una cohort prospectiva de 321 nens nascuts al SCIAS.Hospital de Barcelona, amb l'objectiu d'avaluar la confiabilitat dels qüestionaris aplicats als 24 mesos d'edat corregida i 48 mesos d'edat cronològica del ASQ en espanyol i la seva correlació entre ambdues avaluacions. Una cohort de 227 nens controlats a la Clínica Alemana de Santiago de Xile, amb l'objectiu d'estudiar la validesa predictiva del ASQ en espanyol aplicat als 8 i 18 mesos d'edat cronològica en els nascuts a terme i d'edat corregida en els prematurs, o als 30 mesos d'edat cronològica, per a detectar aquells nens que tindran dèficit cognitiu a l'etapa escolar. Finalment, es va fer una revisió sistemàtica de la literatura per analitzar la capacitat del ASQ i els CCDRP per predir baix rendiment cognitiu o acadèmic en nens de població general. Resultats: A Barcelona s'evidencià que el ASQ és un instrument confiable pel cribratge del desenvolupament psicomotor (alfa de Cronbach pel puntatge global 0,78/0,79), existint una correlació positiva i significativa entre les avaluacions realitzades als 24 i 48 mesos. La presència de 2 o més dominis en zona de risc als 24 mesos va ser predictiu de dèficit del desenvolupament als 48 mesos (Odds Ratio (OR)=140 [95% IC 14,85;3575,65]). A Xile, la capacitat predictiva del ASQ per identificar aquells nens que tenien menor rendiment cognitiu en l'etapa escolar va ser satisfactori (àrea sota la corba (AUC) 0,77 [IC95% 0,65- 0,89]) i comparable amb la prova diagnòstica de referència (p=0.58). Considerant com a minim un domini en zona de risc la sensibilitat va ser 66,7% i l'especificitat 71,7%. Finalment, a través d'una revisió sistemàtica de la literatura es van identificar 8 cohorts avaluades amb ASQ que informaren associacions en general "positives" entre l'avaluació precoç del desenvolupament i el rendiment cognitiu o acadèmic posterior, amb AUC entre 0.66 i 0,87, i OR superiors a 3. Es va trobar un efecte mirall en revisar la sensibilitat i l'especificitat de les cohorts. La heterogeneitat dels estudis no va permetre realitzar un metanàlisi ni anàlisi de subgrups. Conclusions : El ASQ és confiable i té una adequada correlació i capacitat per a predir les dificultats del desenvolupament entre els 2 i 4 anys a Barcelona. A més llarg termini, a Xile, es va demostrar que les avaluacions fetes als 8, 18 o 30 mesos tenen una adequada capacitat predictiva de les dificultats cognitives en l'etapa escolar. Aquests resultats van ser corroborats a través d'una revisió sistemàtica de la literatura. Són precisos estudis adicionals per conèixer l'impacte de les diferents adaptacions, els diferents contextos socioculturals, factors de risc biològic i les edats d'avaluació, en la capacitat predictiva del ASQ com a CCDRP.Antecedentes: los cuestionarios de cribado del desarrollo basados en el reporte de padres o cuidadores (CCDRP) han ganado cada vez mayor difusión. De estos, el más conocido a nivel mundial es el Ages and Stages Questionnaire (ASQ), instrumento que se ha utilizado en Cataluña y validado en Chile, existiendo una brecha en cuanto al conocimiento de su capacidad predictiva a más largo plazo. Objetivo: Determinar la confiabilidad y validez predictiva del ASQ para el cribado de dificultades del desarrollo. Métodos: Se realizaron tres trabajos de investigación. Una cohorte prospectiva de 321 niños nacidos en el SCIAS.Hospital de Barcelona, con el objeto de evaluar la confiabilidad de los cuestionarios aplicados a los 24 meses de edad corregida y 48 meses de edad cronológica del ASQ-3 en español y la correlación entre ambas evaluaciones. Una cohorte de 227 niños controlados en Clínica Alemana de Santiago de Chile, con el objetivo de estudiar la validez predictiva del ASQ aplicado a los 8, 18 meses de edad cronológica en niños nacidos a término y edad corregida en prematuros, o 30 meses de edad cronológica, para detectar los niños que tendrán déficit cognitivo en la etapa escolar. Finalmente se realizó una revisión sistemática de la literatura para analizar la capacidad del ASQ y los CCDRP para predecir bajo rendimiento cognitivo o académico en niños de población general. Resultados: En Barcelona se evidenció que ASQ es un instrumento confiable para el cribado del desarrollo psicomotor (alfa de Cronbach para el puntaje global 0,78/0,79), existiendo una correlación positiva y significativa entre las evaluaciones realizadas a los 24 y 48 meses. La presencia de 2 o más dominios en zona de riesgo a los 24 meses fue predictor de déficit del desarrollo a los 48 meses (Odds Ratio (OR) =140 [95% IC 14,85;3575,65]). En Chile, la capacidad predictiva del ASQ para identificar aquellos niños que tenían menor rendimiento cognitivo en la etapa escolar fue satisfactorio (área bajo la curva (AUC) 0,77 [IC95% 0,65- 0,89] ) y comparable con la prueba diagnóstica de referencia (p=0.58). Considerando al menos un dominio en zona de riesgo la sensibilidad fue 66,7% y la especificidad 71,7%. Finalmente, a través de una revisión sistemática de la literatura se identificaron 8 cohortes evaluadas con ASQ que reportaron asociaciones en general "positivas" entre la evaluación temprana del desarrollo y el rendimiento cognitivo o académico posterior, con AUC entre 0.66 y 0.87, y OR superiores a 3. Un efecto en espejo se encontró al revisar la sensibilidad y especificidad de las cohortes. La heterogeneidad de los estudios no permitió realizar un metaanálisis ni análisis de subgrupos. Conclusiones. El ASQ es confiable y tiene una adecuada correlación y capacidad para predecir las dificultades del desarrollo entre los 2 y 4 años en Barcelona. A más largo plazo, en Chile, se demostró que las evaluaciones realizadas a los 8,18 o 30 meses tienen adecuada capacidad predictiva de las dificultades cognitivas en la etapa escolar. Estos resultados fueron corroborados a través de una revisión sistemática de la literatura. Se requieren estudios adicionales para conocer el impacto de las distintas adaptaciones, los diferentes contextos socioculturales, factores de riesgo biológicos y las edades de evaluación, en la capacidad predictiva del ASQ, como CCDRP.Introduction: Parent/caregiver completing developmental screening questionnaires (DSQs) have become increasingly widespread. Worldwide, the most well-known is the Ages and Stages Questionnaire (ASQ), an instrument that has been used in Catalonia and validated in Chile; however, there is a gap in the knowledge of its predictive capacity in the longer term. Objective: To determine the reliability and predictive validity of the ASQ for the screening of developmental difficulties. Methods: Three research studies were carried out. A prospective cohort of 321 children born at the SCIAS - Hospital in Barcelona, in order to evaluate the reliability of the questionnaires administered at 24 months of corrected age and 48 months of chronological age of the ASQ-3 in Spanish and the correlation between both evaluations. A cohort of 227 children seen at Clínica Alemana de Santiago, Chile, to study the predictive validity of the ASQ applied at 8 and 18 months of chronological age in full-term children and corrected age in preterm, or 30 months of chronological age, to detect children who will have cognitive deficits at school. Finally, a systematic review of the literature was carried out to analyze the ability of the ASQ, and other DSQs, to predict low cognitive or academic performance in children of the general population. Results: In Barcelona, it was observed that ASQ is a reliable instrument for psychomotor development screening (Cronbach's alpha for the global score 0.78/0.79), with a positive and significant correlation between the assessments made at 24 and 48 months. The presence of 2 or more domains in the risk zone at 24 months was predictive of developmental deficit at 48 months (Odds Ratio (OR) =140 [95% CI 14.85;3575.65]). In Chile, the predictive ability of the ASQ to identify children with lower cognitive performance at school was satisfactory (area under the curve (AUC) 0.77 [95% CI 0.65- 0.89]) and comparable with the reference diagnostic test (p=0.58). Considering at least one domain in the risk zone, it presented a 66.7% sensitivity and 71.7% specificity. Finally, through a systematic review of the literature, we identified 8 cohorts evaluated with the ASQ that reported overall "positive" associations between early developmental screening and later cognitive or academic performance, with AUC between 0.66 and 0.87, and OR higher than 3. We observed a mirror effect when reviewing the sensitivity and specificity of the cohorts. The heterogeneity of the studies did not allow meta-analysis or subgroup analysis. Conclusions: The ASQ is reliable and has an adequate correlation and capacity to predict developmental difficulties between two and four years of age in Barcelona. In the longer term, in Chile, it was demonstrated that the assessments performed at 8, 18, or 30 months have an adequate predictive capacity of cognitive difficulties in the school stage. These results were corroborated through a systematic review of the literature. Further studies are needed to determine the impact of different adaptations, sociocultural contexts, biological risk factors, and assessment ages on the predictive ability of the ASQ, such as parent-repot DSQs