Background: Hospitalization and deaths due to cardiovascular diseases (CVD), have a peak in frequency during winter. Aim: To assess the existence of seasonal variation in deaths due to acute myocardial infarction (AMI) in Chile. Material and Methods: Analysis of death report databases available at the website of the Chilean Ministry of Health. The seasonality of deaths due to AMI (codes ICD-10 I21, I22, I23) occuring in Chile between 2001-2016 were analyzed using a geometric model assuming a sinusoidal cyclic pattern. Results: During the period 2001-2016, a total of 94,788 deaths due to AMI were registered, corresponding to 93,349 corrected deaths. Of the latter, 29.2% occurred in winter, 24.9% in spring, 24.0% in autumn and 21.8% in summer. The geometric model showed a marked sinusoidal pattern for the aggregated data. The peak-to-low ratio of deaths was 1.41 (95% CI 1.38-1.44). The peak of deaths occurred during July in 14 out of 16 years analyzed. Conclusions: In Chile, deaths due to AMI have a marked seasonal pattern, characterized by a higher number of deaths in winter and a lower number in summer.

Background: Smoking is one of the main causes of death among adults worldwide. Aim: To characterize smoking among Chilean older people, according to sociodemographic and clinical variables. Material and Methods: Secondary analysis of data obtained during the National Health Survey 2009-10, selecting individuals aged 60 years and older. Expansion factors were used due to the complex design of the sample. Prevalence and characteristics of smoking were calculated, according to age, sex, educational level, marital status, healthcare insurance system and comorbidities. Results: Nineteen percent of older people were actual smokers, and 85% of these smokers were aged between 60 and 69 years. Forty-five percent were highly dependent to nicotine and 73% reported their intention to quit smoking. Conclusions: There is a high prevalence of tobacco smoking among Chilean older people. Prevention measures are needed.

Abstracts: Cardiovascular diseases and cancer are culturally transmitted chronic diseases and the two main causes of death globally. In addition to their high morbidity and mortality, these diseases are closely related, due to their common risk factors and biological mechanisms. The high incidence of cardiovascular diseases in cancer patients is widely known phenomenon, which has oriented the development of the interdisciplinary field of cardio-oncology Nonetheless, there is emerging evidence in the last decade suggesting a potential role for cardiovascular diseases in the onset of cancer. A recent publication by Meijers et al in the scientific cardiovascular journal Circulation showed that heart failure significantly contributes to tumor growth, confirming previous epidemiological findings suggesting this hypothesis. Moreover, this study indicates that tumor growth may be stimulated by the secretion of factors from the failing heart, opening a wide spectrum of research areas in what may be suggested as a new field in medicine that would seek to develop new strategies to treat and prevent cancer in patients with cardiovascular diseases. This article will review shared risk factor and common cellular and molecular pathways in cardiovascular diseases and cancer, the contribution of Meijers et al to a better understanding of the connection of these diseases and future perspectives in light of the new evidence.

Resumen: Las enfermedades cardiovasculares y el cáncer son enfermedades crónicas transmisibles culturalmente, y las dos causas principales de mortalidad en el mundo. Además del gran impacto sobre la mortalidad y morbilidad, estas enfermedades han mostrado un alto grado de relación entre ellas debido, entre otras razones, a que comparten factores de riesgo y mecanismos biológicos. La alta incidencia de enfermedad cardiovascular en pacientes con cáncer es un fenómeno conocido que ha orientado el desarrollo del campo interdisciplinario de la cardio-oncología. Sin embargo, en la última década han surgido evidencias que muestran el papel que desempeñan las enfermedades cardiovasculares en el desarrollo de cáncer. Un estudio reciente publicado por Meijers y cols, en agosto de 2018 en Circulation, mostró que la insuficiencia cardiaca post-infarto del miocardio contribuye significativamente al desarrollo del cáncer de colón, apoyando lo obtenido en estudios epidemiológicos anteriores. Este estudio también sugiere que el crecimiento tumoral podría producirse por factores secretados por el corazón insuficiente abriendo un amplio grupo de posibilidades de investigación en lo que sería un nuevo campo de la medicina cuyo propósito sería el desarrollo de nuevas estrategias para el seguimiento y tratamiento del cáncer en pacientes con enfermedades cardiovasculares. El presente artículo revisa los factores de riesgo, y mecanismos celulares y moleculares, que son comunes en las enfermedades cardiovasculares y el cáncer, la contribución del trabajo de Meijers y cols hacia un mayor entendimiento de la interrelación entre estas patologías y las perspectivas futuras con respecto a los nuevos hallazgos.

Considering that a high proportion of the Chilean general population smokes, the Chilean Society of Respiratory Diseases in collaboration with the Chilean Societies of Cardiology and, Endocrinology and Diabetes, formed an interdisciplinary group, who issued a set of recommendations for the treatment of the smoker, methodologically advised by experts. These interventions should be prioritized in high-risk groups. Methods The panel elaborated and graded the recommendations following the GRADE methodology. To assess the effect of each intervention, systematic reviews and randomized clinical trials were identified. In addition, a search of studies done with the Chilean population was carried out. For each of the questions, the panel determined the direction and strength of the recommendation through a decision evidence table. Recommendations For all smokers, the panel recommends using brief counseling ABC on non-intervention, using mobile telephone interventions on non-intervention, using text message on non-intervention, (strong recommendation; moderate certainty in the evidence of the effects). For motivated individuals, with indication for quitting drugs the panel recommends using nicotine replacement therapy on non-intervention, using bupropion on non-intervention, using varenicline on non-intervention. (strong recommendation; moderate certainty in the evidence of the effects). Discussion This clinical practice guide provides recommendations based on the evidence for smoking cessation.

Hospitalization is a valuable opportunity for smoking cessation. In Chile this opportunity is wasted. The need to hospitalize is determined by diseases often caused by smoking, this scenario allows the patient to assess not only the consequences of this addiction, but also the importance of stopping tobacco consumption. During hospitalization, the nicotine withdrawal syndrome appears, whose recognition and management is essential to avoid habitual complications: anxiety or delirium. For all of the above mentioned reasons, it is necessary the adequate confrontation of smoking in the hospitalized patient, which is recognized by international accreditation bodies as Joint Commission. A Cochrane metaanalysis 2012 concluded that the two pillars of effective interventions were the multimodal character (counseling and pharmacological treatment), and ambulatory follow-up for more than one month after discharge. The central elements of a brief counseling can be summarized in ABC, where A: ask about smoking; B: give brief advice stating the importance of quitting, and C: provide support for cessation for motivated patients. Although the above-mentioned interventions involve resources for pharmacological support, there seems to be no excuse for implementing simple interventions in Chilean hospitals, such as documenting the smoking status of each patient and offering brief counseling.

Resumen La hospitalización es una oportunidad valiosa para el abandono del tabaquismo, desaprovechada en Chile. La necesidad de hospitalizarse está determinada por enfermedades muchas veces causadas por el consumo de tabaco, este escenario permite al paciente valorar no solo las consecuencias de esta adicción, si no también, la importancia de suspender el consumo. Es esperable que durante la hospitalización aparezca el síndrome de abstinencia de nicotina, cuyo reconocimiento y manejo es fundamental para evitar complicaciones habituales: ansiedad o delirium. Por todo lo anterior, resulta necesario el adecuado enfrentamiento del tabaquismo en el paciente hospitalizado, lo que es reconocido por organismos acreditadores internacionales como Joint Commission. Un metanálisis Cochrane 2012 concluyó que los dos pilares fundamentales de las intervenciones efectivas fueron el carácter multimodal (consejería y tratamiento farmacológico), y el seguimiento ambulatorio por más de un mes posterior al alta. Los elementos centrales de una consejería breve pueden resumirse en el ABC, siendo A: averiguar sobre el consumo de tabaco; B: dar un consejo breve indicando la importancia de dejar de fumar, y C: Ofrecer apoyo para la cesación a los pacientes que se muestren motivados. Si bien las intervenciones mencionadas involucran contar con recursos para apoyo farmacológico, no pareciera haber excusas para seguir sin implementar en los hospitales chilenos intervenciones sencillas como documentar el estado tabáquico de cada paciente y ofrecer consejería breve.

Considering that Chilean population has a high tobacco consumption history, the Chilean Society of Respiratory Diseases in collaboration with the Chilean Societies of Cardiology and, Endocrinology and Diabetes, formed an interdisciplinary group, who issued a set of recommendations for the treatment of the smoker, methodologically advised by experts. These interventions should be prioritized in high-risk groups. Methods: The panel elaborated and graded the recommendations following the GRADE methodology. To assess the effect of each intervention, systematic reviews and randomized clinical trials were identified. In addition, a search of studies done with the Chilean population was carried out. For each of the questions, the panel determined the direction and strength of the recommendation through a decision evidence table. Recommendations: For all smokers, the panel recommends using brief counseling ABC on non-intervention, using mobile telephone interventions on non-intervention, using text message on non-intervention, (strong recommendation; moderate certainty in the evidence of the effects). For motivated individuals, with indication for quitting drugs the panel recommends using nicotine replacement therapy on non-intervention, using bupropion on non-intervention, using varenicline on non-intervention. (strong recommendation; moderate certainty in the evidence of the effects). Discussion: This clinical practice guide provides recommendations based on the evidence for smoking cessation.

RESUMEN Considerando que la población chilena tiene una historia de alto consumo de tabaco la Sociedad Chilena de Enfermedades Respiratorias en colaboración con las Sociedades Chilenas de Cardiología; Endocrinología y Diabetes formó un grupo interdisciplinario que emitió un conjunto de recomendaciones para el enfrentamiento del paciente fumador, asesorado metodológicamente por expertos. Estas intervenciones deben priorizarse en grupos de alto riesgo. Métodos: El panel elaboró y graduó las recomendaciones siguiendo la metodología GRADE. Para estimar el efecto de cada intervención, se identificó revisiones sistemáticas y estudios clínicos aleatorizados. Además, se realizó una búsqueda de estudios realizados con población chilena. Para cada una de las preguntas, el panel determinó la dirección y fuerza de la recomendación mediante una tabla de la Evidencia a la Decisión. Recomendaciones: Para todos los fumadores, el panel recomienda usar consejería breve sobre no intervención, consejería vía telefonía móvil sobre no intervención, y mensajes de texto sobre no intervención (recomendación fuerte; certeza moderada en la evidencia de los efectos). Para los individuos motivados, con indicación de fármacos para dejar de fumar el panel recomienda terapia de reemplazo de nicotina sobre no intervención, bupropión sobre no intervención, vareniclina sobre no intervención (recomendación fuerte; certeza moderada en la evidencia de los efectos). Discusión: Se emiten recomendaciones basadas en la evidencia para el tratamiento del tabaquismo.

mHealth, refers to the use of mobile devices as a telemedicine tool, ideal for promotion, prevention and control of diseases. In Chile, 84.1% of the population has access to the Internet and 80% of accesses are through of mobile devices, this makes the internet and mobile telephony particularly attractive tools for health interventions. Studies involving interventions through text messages to support smoking cessation are not directly extrapolated to our country since most of them come from developed and English-speaking countries, which is why it is necessary to develop and evaluate appropriate interventions for our population.

Resumen La mHealth, se refiere al uso de dispositivos móviles como una herramienta de telemedicina, ideal para la promoción, prevención y control de enfermedades. En Chile, un 84,1% de la población tiene acceso a internet y un 80% de los accesos son a través de dispositivos móviles, esto convierte a internet y la telefonía móvil en herramientas particularmente atractivas para intervenciones en salud. Los estudios que implican intervenciones a través de mensajes de texto para el apoyo a la cesación tabáquica no son directamente extrapolables a nuestro país ya que la mayoría provienen de países desarrollados y de habla inglesa, motivo por el cual es necesario desarrollar y evaluar intervenciones adecuadas para nuestra población.

RESUMO Objetivo Estimar a morbidade e a mortalidade infantis anuais atribuíveis ao tabagismo durante a gestação no Chile em 2008–2012. Métodos As frações atribuíveis populacionais (PAFs) para vários desfechos infantis foram calculadas com base em estimativas de estudos anteriores da prevalência do tabagismo durante a gestação e razões de possibilidades associadas à exposição (tabagismo durante a gestação relativo ao tabagismo fora da gestação). Os casos de morbidade e mortalidade infantis atribuíveis ao tabagismo durante a gestação foram calculados multiplicando-se o número médio anual de casos de morbidade e mortalidade registrados no Chile em 2008–2012 pela PAF correspondente. Resultados As PAFs para 1) recém-nascidos ≤ 27 semanas, 2) recém-nascidos com 28–33 semanas, 3) recém-nascidos com 34–36 semanas e 4) recém-nascidos de termo com baixo peso foram 12,3%, 10,6%, 5,5% e 27,4%, respectivamente. As PAFs para mortes devidas a causas relacionadas à prematuridade e mortes devidas à síndrome de morte súbita do recém-nascido foram 11,9% e 40,0%, respectivamente. Anualmente, 2.054 casos de recém-nascidos prematuros e de termo com baixo peso (1 em 9 casos), 68 mortes devidas a causas relacionadas à assistência pré-natal (1 em 8 casos) e 26 mortes devidas à síndrome de morte súbita do recém-nascido (1 em 3 casos) foram atribuíveis ao tabagismo durante a gestação. Conclusões No Chile, a morbidade e a mortalidade infantis atribuíveis ao tabagismo durante a gestação são inadmissivelmente elevadas. Amplas intervenções individuais e populacionais para o controle do tabagismo devem ser uma prioridade de saúde pública no país, sobretudo em adolescentes e jovens que serão mães das futuras gerações.

ABSTRACT Objective To estimate annual infant morbidity and mortality attributable to prenatal smoking in Chile during 2008−2012. Methods Population-attributable fractions (PAFs) for several infant outcomes were calculated based on previous study estimates of prenatal smoking prevalence and odds ratios associated with exposure (prenatal smoking relative to non-prenatal smoking). Prenatal smoking–attributable infant morbidity and mortality cases were calculated by multiplying the average annual number of morbidity and mortality cases registered in Chile during 2008–2012 by the corresponding PAF. Results PAFs for 1) births ≤ 27 weeks; 2) births at 28–33 weeks; 3) births at 34–36 weeks; and 4) full-term low-birth-weight infants were 12.3%, 10.6%, 5.5%, and 27.4% respectively. PAFs for deaths caused by preterm-related causes and deaths caused by sudden infant death syndrome were 11.9% and 40.0% respectively. Annually, 2 054 cases of preterm-birth and full-term low-birth-weight (1 in 9 cases), 68 deaths caused by preterm-related causes (1 in 8 cases), and 26 deaths caused by sudden infant death syndrome (1 in 3 cases) were attributable to prenatal smoking. Conclusions In Chile, infant morbidity and mortality attributable to prenatal smoking are unacceptably high. Comprehensive individual and population-based interventions for tobacco control should be a public health priority in the country, particularly among female adolescents and young women who will be the mothers of future generations.

RESUMEN Objetivo Calcular las tasas anuales de morbilidad y mortalidad de lactantes atribuibles al tabaquismo prenatal en Chile entre los años 2008 y 2012. Métodos Se calcularon las fracciones atribuibles a la población (FAP) correspondientes a diferentes resultados de salud en lactantes tomando como base la prevalencia estimativa del tabaquismo prenatal y las razones de posibilidad asociadas a la exposición (tabaquismo prenatal frente a tabaquismo no prenatal) calculadas en estudios previos. Los casos de mortalidad y morbilidad de lactantes atribuibles al tabaquismo prenatal se calcularon multiplicando el promedio anual de casos de morbilidad y mortalidad registrados en Chile entre los años 2008 y 2012 por la FAP correspondiente. Resultados Las FAP para los lactantes nacidos 1) a las 27 semanas o menos de gestación; 2) de 28 a 33 semanas de gestación; 3) de 34 a 36 semanas de gestación; y 4) al término de la gestación, pero con peso bajo al nacer, fueron de 12,3%, 10,6%, 5,5% y 27,4%, respectivamente. Las FAP correspondientes a las muertes por causas relacionadas con el nacimiento prematuro y las muertes por síndrome de muerte súbita del lactante fueron de 11,9% y 40,0%, respectivamente. Al año, 2 054 casos de bebés prematuros y de bebés nacidos con peso bajo al término de la gestación (1 de 9 casos), 68 muertes por causas relacionadas con el período prenatal (1 de 8 casos) y 26 muertes causadas por el síndrome de muerte súbita del lactante (1 de 3 casos) fueron atribuibles al tabaquismo prenatal. Conclusiones En Chile, las tasas de morbilidad y mortalidad de lactantes atribuibles al tabaquismo prenatal son inadmisiblemente altas. En el país, las intervenciones integrales para el control del tabaco a nivel individual y poblacional deben ser una prioridad de salud pública, particularmente en las mujeres adolescentes y jóvenes que serán las madres de las generaciones futuras.

Factors associated with therapeutic lifestyle change (TLC) after myocardial infarction (MI) have not been fully investigated in Chile. This study aimed to provide a descriptive examination of facilitators and barriers to TLC after first MI. Methods: Qualitative study based on in-depth interviews and focus groups with cardiologists and patients who had first MI one-year±2 months before the begin-ning of the study. Grounded theory research methods were used to guide sampling and coding of data. Results: Twenty-one patients who had first myocardial infarction and 14 cardiologists participated in in-depth interviews and focus groups until the point of theoretical saturation. Facilitators for TLC included optimism, self-efficacy, faith-based life purpose, positive attitudes by family and friends, social participation, good patient-physician relationship, and positive medical advice. Barriers were: individual (older age, female sex, lower educational level, limiting beliefs, ambi val ence, depressive mood, lack of knowledge on strategies to achieve TLC, financial constraints), family (family crisis, overprotection, im-posing attitudes, unhealthy habits at home), work (work overload and competition between work recovery and TLC), socio-environmental (neighborhood unsafety), and health provider-related (poor patient-physician re-lationship, limiting beliefs among physicians, medical advice centered on restrictions or imprecise, medical training focused on pharmacological therapies and in-terventional procedures over preventive care, and orga-nizational issues). Conclusions: Reported facilitators and barriers enhance understanding of the process of lifestyle change after first myocardial infarction, and might be targets for optimization of secondary preventive strategies among Chilean patients.

Los factores asociados con el cambio terapéutico de estilos de vida (TLC) después de un infarto agudo al miocardio (IAM) no han sido suficientemente investigados en Chile. El objetivo de este estudio fue explorar y describir los facilitadores y barreras para la adopción de TLC en pacientes que han sufrido un primer IAM. Métodos: Estudio cualitativo basado en entrevistas en profundidad y grupos focales con cardiólogos y pacientes que tuvieron un primer IAM un año ± 2 meses antes del inicio del estudio. Se usó metodología de Teoría Fundada para guiar el muestreo y la codificación de los datos. Resultados: Veintiún pacientes con un primer IAM y 14 cardiólogos participaron en las entrevistas en profundidad y grupos focales, hasta el punto de saturación teórica. Facilitadores para TLC incluyeron optimismo, autoeficacia, propósito de vida basado en la fe, actitudes positivas por familiares y amigos, participación social, buena relación médico-paciente, y un consejo médico positivo. Las barreras fueron: individuales (edad avanzada, sexo femenino, bajo nivel educacional, creencias limitantes entre los pacientes, ambivalencia, estado de ánimo depresivo, falta de conocimiento sobre estrategias para lograr TLC, limitaciones financieras), a nivel familiar (crisis de la familia, sobreprotección, imposición de actitudes, hábitos no saludables en el hogar), a nivel laboral (sobrecarga de trabajo y competencia entre la recuperación del trabajo y la adopción de TLC), a nivel socio-ambiental (inseguridad del barrio), y a nivel del proveedor de salud (mala relación médico-paciente, creencias limitantes entre los médicos, consejo médico impreciso o basado en restricciones, formación médica centrada en aspectos farmacológicos e intervencionales por sobre lo preventivo, y problemas de organización). Conclusiones: Los facilitadores y barreras reportados mejoran la comprensión del proceso de cambio de estilos de vida después del primer infarto agudo al miocardio, y pueden contribuir a la optimización de estrategias de prevención cardiovascular secundaria en pacientes chilenos.

Objective: To examine the population effectiveness of nicotine replacement therapies (NRTs), either with or without professional counselling, and provide evidence needed to better inform healthcare coverage decisions. Methods: A prospective cohort study was conducted in three waves on a probability sample of 787 Massachusetts adult smokers who had recently quit smoking. The baseline response rate was 46%; follow-up was completed by 56% of the designated cohort at wave 2 and 68% at wave 3. The relationship between relapse to smoking at follow-up interviews and assistance used, including NRT with or without professional help, was examined. Results: Almost one-third of recent quitters at each wave reported to have relapsed by the subsequent interview. Odds of relapse were unaffected by use of NRT for > 6 weeks either with (p = 0.117) or without (p = 0.159) professional counseling and were highest among prior heavily dependent persons who reported NRT use for any length of time without professional counselling (OR 2.68). Conclusions: This study finds that persons who have quit smoking relapsed at equivalent rates, whether or not they used NRT to help them in their quit attempts. Cessation medication policy should be made in the larger context of public health, and increasing individual treatment coverage should not be at the expense of population evidence-based programmes and policies.

Background: The neutrophil/lymphocyte ratio is an effective marker of inflammation ana can have prognostic value in surgical patients. Aim: To evaluate the effect of an increased neutrophil/lymphocyte ratio (NLR) on perioperative complications ana overall ana disease-free survival in patients undergoing elective resection for stage II colon cancer. Material and Methods: Data was obtained from clinical charts, preoperative blood results and hospital records of all patients undergoing an elective curative resection for colon cancer, between 2000 and 2007. Preoperative NLR was calculated. Follow-up was obtained from a prospectively maintained colorectal cancer database, clinical records and questionnaires. Uni and multivariable analysis were performed to identify associations, and survival analysis was performed using Kaplan-Meier curves. Results: One hundred twenty two patients with a mean age of69years (52% males), were evaluated. Median follow-up was 73 months, and overall survival for 1 and 5years was 95% and 68%, respectively. On a multivariable analysis after adjusting for age, sex, tumor depth invasion, use of adjuvant therapies and American Society of Anesthesiology preoperative risk score, an NLR > 5 was associated with an increased perioperative complication rate (odds ratio: 3,06, p = 0,033). Kaplan-Meier survival analysis showed a worse overall and disease-free survival for patients with NLR greater than five. Conclusions: A preoperative NLR of five or more is associated with greater perioperative morbidity and worse oncological outcomes in patients undergoing resection for elective stage II colon cancer.

A special Committee on Internal Medicine and Public Health was established by Sociedad Médica de Santiago (Chilean Society of Internal Medicine) in April 2007 with the duty to write a Consensus Paper on the interaction between both branches of medical profession. The main objective was to find the common grounds on which to construct a positive approach to regain space for Internal Medicine, based on prevalent epidemiológica! features related to adult health issues. The authors describe the reasons to explain the gap between clinical medicine and population health and identify the nature and evolution of chronic diseases as the point of encounter between both. With Chilean health surveys data, they state that chronic diseases explain the high proportion of burden of disease, mortality and disability, and stress that by the year 2025 one in every five inhabitants will be over 65years of age, with ageing as another main problem for the health care sector. Population with multiple risks and multimorbidity is the most important challenge for the Chilean Health Care System. A new model of care is needed to tackle this scenario with new skills regarding psychosocial determinants of health. The leading role of internists and ideally geriatricians, will be crucial in this process and will help the implementation of sound population based interventions. Both individual and community level interventions will help to improve quality of life of Chilean families.

Background: The high prevalence of obesity in children favors the appearance of metabolic syndrome (MS), increasing their cardiovascular risk. Aim: To evaluate components of MSin children and to comtate them with surrogate markers of atherosclerosis and subclinical inflammation. Material and methods: We studied 209 children aged 11.5 ± 2 years (50% girls, 30% prepuberal). Fifty percent had normal weight, 18% were overweight, 29% were obese and 3% were undernourished. A fasting blood sample was obtained to measure lipid levels, glucose, insulin, adiponectin and ultrasensitive C-reactive protein (usCRP). Subclinical atherosclerosis was evaluated using flow mediated dilatation of brachial artery (FMD) and carotid intima-media thicknes (IMT). For diagnosis of MS we adapted Cook's criteria. Results: Five percent of all children and 18% ofthose with overweight had MS. Children with more components had significantly higher fasting insulin and Homeostasis Model Assessment (HOMA) values. Clustering of MS components was also associated to higher values of usCRP and non significantly to lower adiponectin levels. We did not find differences in FMD. In obese children there was a tendency towards a higher IMT with clustering of MS components, although not significant. Conclusions: Children with overweight presented a higher risk of a clusteríng of MS components, which was also associated with insulin resistance and increase in ultrasensitive C reactive protein.