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Long-term therapy-related reproductive health side effects impact the quality of life of hematopoietic stem cell transplantation (HSCT) survivors. In this study, we evaluated the prevalence of gonadal dysfunction (GD) pre- and post-HSCT, analyzed factors associated with GD, and explored rates of fertility assessment (FA) and fertility preservation (FP) in a resource-limited setting. FA and outcomes of patients age ≤45 years undergoing HSCT between June 2000 and May 2018 were collected retrospectively. We included 213 patients with a median age of 26 years. Pre-HSCT FA was performed in 71.8%, with a GD rate of 17%. The rate of GD was not different between the sexes (females, 19.5% versus males, 16.1%; P = .616) and was only associated with increasing age. The rate of cryopreservation in the cohort was 3.3%. Almost one-half (47.7%) of post-HSCT patients completed FA and evidenced an increase in GD rate to 48.9%. Comparing pre-HSCT and post-HSCT GD rates, women had a significant increase (19.5% versus 81.4%; P.001), whereas men did not (16.1% versus 20.4%; P = .76). These results were confirmed by a multiple imputation analysis accounting for missing data. Female sex, pre-HSCT cytotoxic therapy, myeloablative conditioning, and germ cell tumor (GCT) diagnosis were associated with post-HSCT GD. Reproductive health preservation can be positively impacted when FA and FP are prioritized at the initial diagnosis in HSCT candidates, particularly in women of older age and men with a diagnosis of GCT. The low FP success observed urges implementation of strategies that favor accessibility and improve quality of life of HSCT survivors in low- and middle-income countries.

Guidelines recommend discussing fertility preservation with patients with cancer. In Mexico, internists frequently are the primary care provider (PCP) for adults in reproductive age. The knowledge of oncofertility among PCPs in low and middle income countries is poorly known. Internal medicine residents in a tertiary care hospital in Mexico City participated in a survey regarding fertility concepts in cancer patients. Sixty-three residents participated; their median age was 27. Thirty percent reported 0% self-perceived confidence for providing counseling about fertility issues, and 26% reported more than 50% self-perceived confidence. Twenty-eight percent reported not asking patients in reproductive age about satisfied parity/paternity. Eighty-one percent correctly identified patients that should receive fertility counseling, and 68% identified alkylating chemotherapy as having the highest risk of infertility. Fifty-four percent were able to name at least one fertility preservation (FP) strategy for males, whereas 49% were able to name at least one strategy in females. Residents who reported at least 50% self-perceived confidence for providing fertility counseling were more likely to name at least one FP strategy for men (64.7%) versus those who reported less than 50% self-perceived confidence (52.1%), but this result was not statistically significant (p = 0.378). This was similar for FP strategies in women, with 64.7% of more confident residents naming at least one, compared with 43.4% of less confident residents (p = 0.134). Knowledge of FP in patients with cancer is insufficient among internal medicine residents in our institution. Inclusion of oncofertility concepts in the internal medicine program is needed.

Background Increased visceral adiposity, insulin resistance, and β-cell dysfunction predispose to type 2 diabetes (T2D). The Visceral Adiposity Index (VAI) is an indicator of visceral fat function obtained from the association between BMI, Triglycerides, HDL-C, and waist circumference, and is a reliable tool to assess the cardiometabolic risk, however, its association with insulin resistance and decreased β-cell function in primary prevention for T2D has not been fully yielded. Methods This is a retrospective cross-sectional study that included 354 asymptomatic subjects, without any known chronic disease, with at least two risk factors for T2D that underwent an oral glucose tolerance test. Patients with newly diagnosed T2D were excluded from the analysis. Results Participants were 51 ± 8 years old, 72.2% were women, had a mean body mass index of 29.9 ± 6.5 kg/m2 and a median VAI of 3.00. The homeostasis model assessment of insulin resistance (HOMA-IR) (r = 0.324), Matsuda index (r = -0.325), first-phase insulin secretion (S1PhOGTT) (r = 0.138), second-phase insulin secretion (S2PhOGTT) (r = 0.137), HOMA-B (r = 0.224), and disposition index (r = -0.165) were significantly correlated with the VAI. After multiple linear regression analysis, the VAI was independently associated with HOMA-IR (β = 0.305), Matsuda Index (β = -0.303), S1PhOGTT (β = 0.143), S2PhOGTT (β = 0.140), HOMA-B (β = 0.204), and the disposition index (β = -0.146). Likewise, a VAI of 2.23 had a sensitivity/specificity of 81.9% and 41.5%, respectively, for identifying a HOMA-IR ≥ 2.5; and a VAI of 3.00 had a sensitivity/specificity of 61.3% and 41.8%, respectively, for identifying a disposition index ≤1.24. Conclusions The VAI was independently associated with insulin resistance, impaired insulin secretion and β-cell dysfunction in subjects at risk for developing T2D.

Background As the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has remained in Latin America, Mexico has become the third country with the highest death rate worldwide. Data regarding in-hospital mortality and its risk factors, as well as the impact of hospital overcrowding in Latin America has not been thoroughly explored. Methods and findings In this prospective cohort study, we enrolled consecutive adult patients hospitalized with severe confirmed COVID-19 pneumonia at a SARS-CoV-2 referral center in Mexico City from February 26th, 2020, to June 5th, 2020. A total of 800 patients were admitted with confirmed diagnosis, mean age was 51.9 ± 13.9 years, 61% were males, 85% were either obese or overweight, 30% had hypertension and 26% type 2 diabetes. From those 800, 559 recovered (69.9%) and 241 died (30.1%). Among survivors, 101 (18%) received invasive mechanical ventilation (IMV) and 458 (82%) were managed outside the intensive care unit (ICU); mortality in the ICU was 49%. From the non-survivors, 45.6% (n = 110) did not receive full support due to lack of ICU bed availability. Within this subgroup the main cause of death was acute respiratory distress syndrome (ARDS) in 95% of the cases, whereas among the non-survivors who received full (n = 105) support the main cause of death was septic shock (45%) followed by ARDS (29%). The main risk factors associated with in-hospital death were male sex (RR 2.05, 95% CI 1.34–3.12), obesity (RR 1.62, 95% CI 1.14–2.32)—in particular morbid obesity (RR 3.38, 95%CI 1.63–7.00)—and oxygen saturation < 80% on admission (RR 4.8, 95%CI 3.26–7.31). Conclusions In this study we found similar in-hospital and ICU mortality, as well as risk factors for mortality, compared to previous reports. However, 45% of the patients who did not survive justified admission to ICU but did not receive IMV / ICU care due to the unavailability of ICU beds. Furthermore, mortality rate over time was mainly due to the availability of ICU beds, indirectly suggesting that overcrowding was one of the main factors that contributed to hospital mortality.

Background Metabolic diseases are risk factors for severe Coronavirus disease (COVID-19), which have a close relationship with metabolic dysfunction-associated fatty liver disease (MAFLD). Aims To evaluate the presence of MAFLD and fibrosis in patients with COVID-19 and its association with prognosis. Methods Retrospective cohort study. In hospitalized patients with COVID-19, the presence of liver steatosis was determined by computed tomography scan (CT). Liver fibrosis was assessed using the NAFLD fibrosis score (NFS score), and when altered, the AST to platelet ratio index (APRI) score. Mann-Whitney U, Student´s t-test, logistic regression analysis, Kaplan-Meier curves and Cox regression analysis were used. Results 432 patients were analyzed, finding steatosis in 40.6%. No differences in pulmonary involvement on CT scan, treatment, or number of days between the onset of symptoms and hospital admission were found between patients with and without MAFLD. The presence of liver fibrosis was associated with higher severity scores, higher levels of inflammatory markers, requirement of mechanical ventilation, incidence of acute kidney injury (AKI), and higher mortality than patients without fibrosis. Conclusion The presence of fibrosis rather than the presence of MAFLD is associated with increased risk for mechanical ventilation, development of AKI, and higher mortality in COVID-19 patients.

espanolAntecedentes: la informacion regional sobre las caracteristicas de los pacientes con enfermedad por coronavirus (COVID) -19 es necesaria para una mejor comprension de la pandemia. Objetivo: El objetivo del estudio es describir las caracteristicas clinicas de los pacientes con COVID-19 diagnosticados en un centro de atencion terciaria en la Ciudad de Mexico y evaluar las diferencias segun el ambito del tratamiento (ambulatorio versus hospitalario) y la necesidad de cuidados intensivos ( IC). Metodos: Realizamos una cohorte prospectiva, que incluyo pacientes consecutivos con COVID-19 desde el 26 de febrero de 2020 hasta el 11 de abril de 2020. Resultados:Se identificaron 309 pacientes (140 pacientes hospitalizados y 169 pacientes ambulatorios). La mediana de edad fue de 43 anos (rango intercuartilico, 33-54), 59,2% varones y 18,6% trabajadores sanitarios (12,3% de nuestro centro). La mediana del indice de masa corporal (IMC) fue de 29,00 kg / m2 y el 39,6% tenia obesidad. En comparacion con los pacientes ambulatorios, los pacientes hospitalizados eran de mayor edad, tenian comorbilidades, tos y disnea con mayor frecuencia. Veintinueve (20,7%) pacientes hospitalizados requirieron tratamiento en la unidad de CI (UCI). Los antecedentes de diabetes (tipo 1 o 2) y el dolor abdominal fueron mas comunes en los pacientes de la UCI en comparacion con los pacientes que no estaban en la UCI. Los pacientes de la UCI tenian IMC mas altos, frecuencias respiratorias mas altas y saturaciones de oxigeno capilar de aire ambiente mas bajas. Los pacientes de la UCI mostraron una respuesta inflamatoria mas severa segun lo evaluado por el recuento de globulos blancos, recuento de neutrofilos y plaquetas, proteina C reactiva, ferritina, procalcitonina y niveles de albumina. Conclusiones: Los pacientes con comorbilidades, ya sean obesos de mediana edad o ancianos que se quejan de fiebre, tos o disnea, fueron mas propensos a ser ingresados. Al ingreso, los pacientes con diabetes, IMC alto y hallazgos clinicos o de laboratorio compatibles con un estado inflamatorio severo tenian mas probabilidades de requerir IC. EnglishBackground: Regional information regarding the characteristics of patients with coronavirus disease (COVID)-19 is needed for a better understanding of the pandemic. Objective: The objective of the study to describe the clinical features of COVID-19 patients diagnosed in a tertiary-care center in Mexico City and to assess differences according to the treatment setting (ambulatory vs. hospital) and to the need of intensive care (IC). Methods: We conducted a prospective cohort, including consecutive patients with COVID-19 from February 26, 2020 to April 11, 2020. Results: We identified 309 patients (140 inpatients and 169 outpatients). The median age was 43 years (interquartile range, 33-54), 59.2% men, and 18.6% healthcare workers (12.3% from our center). The median body mass index (BMI) was 29.00 kg/m2 and 39.6% had obesity. Compared to outpatients, inpatients were older, had comorbidities, cough, and dyspnea more frequently. Twenty-nine (20.7%) inpatients required treatment in the IC unit (ICU). History of diabetes (type 1 or 2) and abdominal pain were more common in ICU patients compared to non-ICU patients. ICU patients had higher BMIs, higher respiratory rates, and lower room-air capillary oxygen saturations. ICU patients showed a more severe inflammatory response as assessed by white blood cell count, neutrophil and platelet count, C-reactive protein, ferritin, procalcitonin, and albumin levels. By the end of the study period, 65 inpatients had been discharged because of improvement, 70 continued hospitalized, and five had died. Conclusions: Patients with comorbidities, either middle-age obese or elderly complaining of fever, cough, or dyspnea, were more likely to be admitted. At admission, patients with diabetes, high BMI, and clinical or laboratory findings consistent with a severe inflammatory state were more likely to require IC.

Guidelines recommend discussing fertility preservation with patients with cancer. In Mexico, internists frequently are the primary care provider (PCP) for adults in reproductive age. The knowledge of oncofertility among PCPs in low and middle income countries is poorly known. Internal medicine residents in a tertiary care hospital in Mexico City participated in a survey regarding fertility concepts in cancer patients. Sixty-three residents participated; their median age was 27. Thirty percent reported 0% self-perceived confidence for providing counseling about fertility issues, and 26% reported more than 50% self-perceived confidence. Twenty-eight percent reported not asking patients in reproductive age about satisfied parity/paternity. Eighty-one percent correctly identified patients that should receive fertility counseling, and 68% identified alkylating chemotherapy as having the highest risk of infertility. Fifty-four percent were able to name at least one fertility preservation (FP) strategy for males, whereas 49% were able to name at least one strategy in females. Residents who reported at least 50% self-perceived confidence for providing fertility counseling were more likely to name at least one FP strategy for men (64.7%) versus those who reported less than 50% self-perceived confidence (52.1%), but this result was not statistically significant (p = 0.378). This was similar for FP strategies in women, with 64.7% of more confident residents naming at least one, compared with 43.4% of less confident residents (p = 0.134). Knowledge of FP in patients with cancer is insufficient among internal medicine residents in our institution. Inclusion of oncofertility concepts in the internal medicine program is needed.

Aims Insulin resistance (IR) predisposes to type 2 diabetes mellitus (T2DM). Although previous studies have associated serum uric acid concentration with IR in T2DM, its association with impaired insulin secretion and beta-cell dysfunction in subjects at risk for developing T2DM remains uncertain. Thus, we aimed to analyze the association of serum uric acid concentration with IR using surrogate insulin resistance/secretion and beta-cell function indices in subjects at risk for developing T2DM. Methods This is a cross-sectional study that included 354 subjects who underwent an oral glucose tolerance test who had at least two risk factors for T2DM without any chronic disease. Results Participants were 51 ± 8 years old, 72.2% were women, had a mean body mass index of 29.9 ± 6.5 kg/m2 and mean serum uric acid concentration of 5.7 ± 1.3 mg/dL. HOMA-IR, first-phase insulin secretion (S1PhOGTT), second-phase insulin secretion (S2PhOGTT), Matsuda and disposition indices were significantly correlated with serum uric acid concentrations (r = 0.239, r = 0.225, r = 0.201, r = −0.287, r = −0.208; respectively). After multiple linear regression analysis, serum uric acid concentration was independently associated with HOMA-IR (β = 0.283), HOMA-B (β = 0.185), S1PhOGTT (β = 0.203), S2PhOGTT (β = 0.186), and Matsuda Index (β = −0.322). A serum uric acid concentration of 5.5 mg/dL had the best sensitivity/sensibility to identify subjects with IR (HOMA-IR ≥2.5). Conclusions Serum uric acid concentration is significantly associated with IR and impaired insulin secretion, but not with beta-cell dysfunction, in subjects at risk for developing T2DM.

Background Rheumatoid arthritis (RA) patients present an increased risk of cardiovascular (CV) morbidity and mortality compared to the general population. Patients from Latin-America present distinctive features and some of them are relevant when assessing CV risk. EULAR recommendations include CV risk assessment for all the patients at least once every 5 years and its reconsideration following major changes in anti-rheumatic therapy. Importantly, failure to identify and manage CV comorbidity in RA patients has been recognized by rheumatologists, although there is no information in Latin-America. Objectives To investigate knowledge about EULAR recommendations for RA-CV risk assessment/management (K-EULAR-R) among internal medicine and rheumatology fellows from an academic and tertiary care level center, to identify physician’s perception about responsible(s) for CV risk assessments and about major barriers to perform the assessments and to investigate the appropriated identification of major CV risk factors. Potential differences among both group of trainees were additionally investigated. Methods Internal medicine fellows (N=105, 1st to 4th grade participants were represented) and rheumatology fellows (N=10, 4 from first grade and 6 from second grade) were invited to anonymously answer a questionnaire designed by 2 investigators to investigate K-EULAR-R and integrated by 11 items classified in 3 categories: “general knowledge about CV risk in RA patients” (4 items), “timing of CV risk assessment” (4 items) and “appropriated statin use” (3 items). In addition, fellows were directed to select and rate main responsible for CV risk assessment (5 options), major barriers to apply EULAR recommendations (6 options), and to correctly identify CV risk factors (20 options). After questionnaire completion, an overall-CV-knowledge-Likert scale (superior, borderline or inferior) was assigned to each participant by an independent observer. The study received IRB approval. Descriptive statistic was used and questionnaire was scored to a decimal scale. Results Ninety-three (85%) internal medicine fellows and 10 (100%) rheumatology fellows participated. Rheumatology fellows scored higher in the K-EULAR-R questionnaire when compared to internal medicine fellows (6.9±1.4 vs. 5.5±1.4, p=0.004) and the higher score was replicated in the category of “general knowledge about CV risk” (8.3±2.0 vs 5.3±2.5, p=0.001), meanwhile no differences were detected in the scoring of the categories “timing of CV risk assessment” and “appropriated statin use”. No differences among grades within each group were identified. The majority of the rheumatology fellows rated themselves as the specialist responsible for CV risk assessment (80%); meanwhile this percentage decreased to 45.7% among the internal medicine fellows (p=0.084); fellows from both groups identified lack of time during rheumatic evaluations as the main barrier to perform CV risk assessment (60% and 57%, respectively). Adequate CV risk factor identification varied from 30% (for contraceptive use) to 100% (for smoking habit), and these% were similar among both groups. Up to 82.5% of the fellows identified incorrectly ≥ 1 CV risk factor and high serum triglyceride levels was the highest (49%). Conclusion Knowledge about CV risk management in RA patients was suboptimal among trainees in internal medicine and rheumatology from an academic and tertiary care level center in Mexico City; trainees in rheumatology performed better. There is a need to reinforce the topic during fellow’s residency. Disclosure of Interests None declared

Background The prescription of parenteral nutrition (PN) in hospitalised patients requires an estimation of the energy requirements. Most studies employing prediction equations (PEs) to estimate energy requirements have focused on critically ill patients. The present study aimed to evaluate several PEs of the resting energy expenditure (REE) to identify the most accurate equation for estimating the REE required for PN. Methods This cross-sectional and descriptive study included patients hospitalised with medical or surgical diagnoses, making them candidates for PN. Epidemiological data, the reason for hospital admission, nutritional screening results, characteristics of the PN administered and REE by indirect calorimetry (IC) were recorded and, subsequently, PEs were calculated. Results In total, 116 patients were recruited with a mean (SD) age of 56.7 (13.8) years and body mass index of 21.3 (4.25) kg m-2 . The diagnosis was medical in 52% of patients and surgical in 48%. The mean (SD) REEs of patients, according to IC, were: 6.11 (1.18) MJ [1461 (281) kcal]; and according to PEs: Mifflin, 5.07 (1.05) MJ [1212 (252) kcal]; Owen, 5.43 (0.72) MJ [1298 (172) kcal]; Harris-Benedict, 5.38 (0.85) MJ [1285 (204) kcal]; Ireton-Jones, 6.20 (1.69) MJ [1481 (403) kcal]; and short equation, 6.12 (0.92) MJ [1464 (220) kcal]. A comparison of the results obtained for the REE by IC and with PEs indicated that the short equation had less bias than the other equations, with an accuracy of 54% CONCLUSIONS: In hospitalised patients who receive PN, determination of the REE should ideally be made by IC. PEs are acceptable but not exact and so their estimation could overfeed or underfeed the patient.

Table S1. Repeated measures ANOVA. (DOCX 13 kb)

Background Hospital length-of-Stay has been traditionally used as a surrogate to evaluate healthcare efficiency, as well as hospital resource utilization. Prolonged Length-of-stay (PLOS) is associated with increased mortality and other poor outcomes. Additionally, these patients represent a significant economic problem on public health systems and their families. We sought to describe and compare characteristics of patients with Normal hospital Length-of-Stay (NLOS) and PLOS to identify sociodemographic and disease-specific factors associated with PLOS in a tertiary care institution that attends adults with complicated diseases from all over Mexico. Materials and methods We conducted a retrospective analysis of hospital discharges from January 2000-December 2017 using institutional databases of medical records. We compared NLOS and PLOS using descriptive and inferential statistics. PLOS were defined as those above the 95th percentile of length of hospitalization. Results We analyzed 85,904 hospitalizations (1,069,875 bed-days), of which 4,427 (5.1%) were PLOS (247,428 bed-days, 23.1% of total bed-days). Hematological neoplasms were the most common discharge diagnosis and surgery of the small bowel was the most common type of surgery. Younger age, male gender, a lower physician-to-patient ratio, emergency and weekend admissions, surgery, the number of comorbidities, residence outside Mexico City and lower socioeconomic status were associated with PLOS. Bone marrow transplant (OR 18.39 [95% CI 12.50–27.05, p

Background Type 2 diabetes mellitus has become one of the most important public health concerns worldwide. Due to its high prevalence and morbidity, there is an avid necessity to find new therapies that slow the progression and promote the regression of the disease. Imatinib mesylate is a tyrosine kinase inhibitor that binds to the Abelson tyrosine kinase and related proteins. It enhances β-cell survival in response to toxins and pro-inflammatory cytokine. The aim of this study is to evaluate the effect of imatinib on fasting plasma glucose in subjects with normal fasting glucose, subjects with impaired fasting glucose and in subjects with type 2 diabetes mellitus. Methods We identified 284 subjects diagnosed with chronic myeloid leukemia or gastrointestinal stromal tumors from the Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran database. 106/284 subjects were treated with imatinib. We compared the effect of imatinib on fasting plasma glucose after 1 and 6 months of treatment. We used ANOVA test of repeated samples to determine statistical significance in fasting plasma glucose before imatinib treatment and the follow-up. Statistical analysis was performed with Statistical Package for the Social Sciences v22. Results We included a total of 106 subjects: 76 with fasting plasma glucose concentrations

Background: Magnesium acts as a cofactor in many intracellular reactions including phosphorylation of the insulin receptor; therefore, its imbalance can potentially cause insulin resistance. Low serum magnesium concentration has been associated with the development of metabolic syndrome and type 2 diabetes mellitus. Objective: To study the association between the daily dietary magnesium intake and insulin resistance estimated by the homeostatic model assessment of insulin resistance and homeostatic model assessment 2, as well as insulin sensitivity estimated by the Matsuda index. Methods: In a university affiliated medical center, 32 participants (22 women, 10 men) that had an indication for testing for type 2 diabetes mellitus with an oral glucose tolerance test were enrolled in this cross-sectional, comparative study. Clinical and biochemical evaluations were carried out including an oral glucose tolerance test. Hepatic insulin resistance index, homeostatic model assessment 2, homeostatic model assessment of insulin resistance, and Matsuda insulin sensitivity were calculated for each participant. They were asked to recall their food ingestion (24 hours) of three days of the past week, including a weekend day; magnesium intake was calculated according to the food nutritional information. Results: The low dietary magnesium intake group (< 4.5 mg/kg/day) had a higher two-hour insulin concentration after an oral glucose tolerance test compared to those with high dietary magnesium (119.5 [73.0-190.6] vs. 63.5 [25.4-114.2]; p = 0.008), and insulin sensitivity assessed by the Matsuda index was higher in the high dietary magnesium intake group (4.3 ± 3.1 vs. 2.4 ± 1.5; p = 0.042). In multiple linear regression analysis a higher dietary magnesium intake was independently associated (β = 4.93; p = 0.05) with a better insulin sensitivity estimated by the Matsuda index. Conclusions: Our results suggest that higher magnesium intake is independently associated with better insulin sensitivity in patients at risk for type 2 diabetes mellitus. (Rev Inves ClIn. 2017;69:40-6)

Introduction: There is little information about the association of thyroid function (TF) with body fat percentage (BF%). Objective: We aimed to evaluate the association between TF and BF%. We also evaluated the association of TF with other variables including insulin resistance (IR). Methods: We included patients from our outpatient clinic with normal TF. A complete evaluation was done, including TF tests: thyroid stimulating hormone (TSH), total triiodothyronine (T3), total thyroxine (T4), 3 hr oral glucose tolerance test (OGTT), and BF% measured with electrical bioimpedance. We divided the population in 2 groups in terms of BF% and compared the TF in each group. Correlation and linear regression analyses were done to evaluate the association of TSH and T3 with BF%, and IR. Results: We evaluated 203 patients (35.9% male). The mean age of the studied subjects was 38.9±13.5 years, with a body mass index (BMI) of 32.7±8.7kg/m2, and a mean BF% of 38.4±9.5%. Between men and women, there were no differences in T3, T4, free thyroxine index (FTI), and TSH. In men, obese patients had more T3 (1.81±0.53 vs 1.57±0.25nmol/L, p=0.04). In women, there were no differences in T3 concentrations, and obese patients had more TSH (2.12±0.9 vs 1.65±0.8mIU/mL, p=0.04). After weight adjustment, we identified a significant correlation between BF% and TSH (r=0.17, p=0.02), and after age and weight adjustment, we identified a significant correlation between T3 and the Homeostasis Model Assessment of insulin resistance (HOMA-IR) (r=0.38, p

An outbreak caused by the novel swine-origin influenza A (H1N1) virus was identified in Mexico in late March 2009. The objective of this report is to describe the organization of a tertiary care center in Mexico City during the contingency. We describe the education program, the hospital organization and triaging, and unforeseen overwhelming circumstances. Educational plans were directed to follow standard, contact, and droplet precautions and to condition behavior to avoid touching the eyes, nose, or mouth. N95 respirators were distributed only to perform respiratory procedures. By the fifth month into the epidemic, four patients with hospital-acquired influenza, 467 workers with respiratory symptoms suggestive of influenza (16% of our staff), and 96 workers with confirmed novel influenza A (3% of our staff) were identified. During the first 2 months of the epidemic, 44,225 people went through the triages and only 1503 (3.3%) reached the emergency room. By the fifth month into the epidemic, four small institutional influenza outbreaks (