Development and external validation of a model to predict multidrug-resistant bacterial infections in patients with cirrhosis.

With the increasing rate of infections caused by multidrug-resistant organisms (MDRO), selecting appropriate empiric antibiotics has become challenging. We aimed to develop and externally validate a model for predicting the risk of MDRO infections in patients with cirrhosis. METHODS: We included patients with cirrhosis and bacterial infections from two prospective studies: a transcontinental study was used for model development and internal validation (n = 1302), and a study from Argentina and Uruguay was used for external validation (n = 472). All predictors were measured at the time of infection. Both culture-positive and culture-negative infections were included. The model was developed using logistic regression with backward stepwise predictor selection. We externally validated the optimism-adjusted model using calibration and discrimination statistics and evaluated its clinical utility. RESULTS: The prevalence of MDRO infections was 19% and 22% in the development and external validation datasets, respectively. The model's predictors were sex, prior antibiotic use, type and site of infection, MELD-Na, use of vasopressors, acute-on-chronic liver failure, and interaction terms. Upon external validation, the calibration slope was 77 (95% CI .48-1.05), and the area under the ROC curve was .68 (95% CI .61-.73). The application of the model significantly changed the post-test probability of having an MDRO infection, identifying patients with nosocomial infection at very low risk (8%) and patients with community-acquired infections at significant risk (36%). CONCLUSION: This model achieved adequate performance and could be used to improve the selection of empiric antibiotics, aligning with other antibiotic stewardship program strategies.

Norfloxacin prophylaxis effect on multidrug resistance in patients with cirrhosis and bacterial infections.

It is unclear whether norfloxacin predisposes to infections by multidrug-resistant organisms (MDROs). We aimed to evaluate if patients with cirrhosis receiving norfloxacin prophylaxis at the time of the diagnosis of bacterial infections were more likely to present a multidrug-resistant isolate than those without prophylaxis. This is a cross-sectional study of hospitalized patients with cirrhosis and bacterial infections from Argentina and Uruguay (NCT03919032) from September 2018 to December 2020. The outcome variable was a multidrug-resistant bacterial infection. We used inverse probability of treatment weighting to estimate the odds ratio (OR) of norfloxacin on infection caused by MDROs considering potential confounders. Among the 472 patients from 28 centers, 53 (11%) were receiving norfloxacin at the time of the bacterial infection. Patients receiving norfloxacin had higher MELD-sodium, were more likely to have ascites or encephalopathy, to receive rifaximin, beta-blockers, and proton-pump inhibitors, to have a nosocomial or health-care-associated infection, prior bacterial infections, admissions to critical care units or invasive procedures, and to be admitted in a liver transplant center. In addition, we found that 13 (24.5%) patients with norfloxacin and 90 (21.5%) of those not receiving it presented infections caused by MDROs (adjusted OR 1.55; 95% CI: 0.60-4.03; p = 0.360). The use of norfloxacin prophylaxis at the time of the diagnosis of bacterial infections was not associated with multidrug resistance. These results help empiric antibiotic selection and reassure the current indication of norfloxacin prophylaxis in well-selected patients.Study registration number: NCT03919032.

Monitoreo serológico y psicológico en personal de salud durante el comienzo de la pandemia COVID-19 / Serological and psychological monitoring of healthcare workers during the start of the COVID-19 pandemic

Introducción: el personal de salud (PdS) es esencial en la lucha contra el COVID-19. Al inicio de la pandemia, el riesgo de adquirir la enfermedad en este grupo era desconocido. Buscamos estimar incidencia y prevalencia de anticuerpos anti-SARS-CoV-2, y prevalencia de burnout en una cohorte de PdS durante la pandemia COVID-19, así como valorar la prevalencia de burnout y depresión en la cohorte. Materiales y métodos: cohorte prospectiva conformada por médicos que atendían pacientes COVID-19 desde marzo de 2020 hasta enero de 2021, en un hospital de alta complejidad de la ciudad de Buenos Aires. Se evaluó IgM e IgG anti-SARS-CoV-2 quincenalmente durante 3 meses, así como la presencia de síntomas compatibles y factores asociados a la exposición. Se remitió a participantes con alteraciones de la esfera psíquica a contacto con el equipo de salud mental del hospital. Resultados: se incluyeron 52 participantes; de ellos, 31 eran mujeres; mediana de edad 32 años (rango 25-58). La mediana de horas semanales de trabajo autoinformadas fue 48 (IIC [intervalo intercuartil] 40-69,5). Inicialmente todos fueron PCR SARS-CoV-2 negativos en hisopado nasal; 11 (21,50% IC 95%; 9,62-32,53%) tuvieron COVID-19 sintomático con anticuerpos positivos. Los factores con mayor asociación a riesgo de COVID-19 fueron anosmia/disgeusia OR 403,33 (IC 95%; 47,60-3417,02), fiebre OR 172,53 (IC 95%; 28,82-1032,65), mialgias OR 41,97 (IC 95%; 8,08-217,84), conviviente con COVID-19 OR 28,17 (IC 95%; 5,67-179,97). Cerca del 40% presentaba alteraciones en las escalas de medición de burnout o depresión. Discusión: la incidencia hallada coincide con las cifras informadas acerca de personal de salud en la etapa inicial de la pandemia en la Argentina. Otro aspecto similar fue una mayoría de infecciones de curso leve, sin ningún paciente hospitalizado. No obstante, se halló una elevada incidencia de alteraciones de la esfera psíquica, tanto al comienzo como al final del seguimiento. Conclusiones: la incidencia de positivización de anticuerpos anti-SARS-CoV-2 fue cercana al 20%. No evidenciamos infecciones presintomáticas o asintomáticas. En cambio, la prevalencia de burnout y depresión fue elevada. La salud mental es un componente del personal de salud que debe ser priorizado en situaciones futuras de impacto similar. (AU)

Introduction: healthcare personnel are essential in the response against COVID-19. At the beginning of the pandemic the risk of acquiring the disease in this group was unknown. We sought to estimate incidence and prevalence of anti SARS-CoV-2 antibodies, as well as burnout prevalence in a cohort of healthcare staff during the pandemic, as well as assessing the prevalence of burnout and depression in this group. Materials and methods: prospective cohort formed by physicians tending to COVID-19 patients from march 2020 to january 2021 in a high-complexity hospital in the city of Buenos Aires. We evaluated anti SARS-CoV-2 IgM and IgG each 15 days for 3 months as well as the presence of compatible symptoms and factors associated to exposition to the virus. Patients showing signs of burnout and/or depression were referred to proper care by the mental health team in the hospital. Results: we included 52 patients, 31 women, median age was 32 years (range 25 - 58). Median amount of self-reported hours worked each week was 48 (IQR 40 - 69.5). Initially all participants had a negative COVID-19 PCR nasopharyngeal swab; 11 (21.50% CI95% 9.62 - 32.53%) had symptomatic COVID-19 with positive antibodies. Factors showing stronger association with testing positive were anosmia/dysgeusia OR 403.33 (CI95% 47.60-3417.02), fever OR 172.53 (CI95% 28.82 - 1032.65), myalgia OR 41.97 (CI95% 8.08 - 217.84), cohabitation with confirmed COVID-19 case OR 28.17 (CI95% 5.67 - 179.97). Near 40% showed alterations in burnout or depression scales. Discussion: the incidence rate we found was like reported values in the initial stages of the pandemic in Argentina. Another similarity was that all cases were mild; no hospitalization was required for any participant. We found an elevated incidence of alterations in the psychic sphere, both at the beginning and end of the follow up period. Conclusions:the incidence of positive SARS-CoV-2 antibodies was around 20%. No pre or asymptomatic cases were identified. Burnout and depression incidence was high. Mental health is a component that should never be overlooked in similar situations to come. (AU)

Safety and effectiveness of RBD-specific polyclonal equine F(ab´)2 fragments for the treatment of hospitalized patients with severe Covid-19 disease: A retrospective cohort study.

BACKGROUND: Passive immunotherapy has been evaluated as a therapeutic alternative for patients with COVID-19 disease. Equine polyclonal immunotherapy for COVID-19 (EPIC) showed adequate safety and potential efficacy in a clinical trial setting and obtained emergency use authorization in Argentina. We studied its utility in a real world setting with a larger population. METHODS: We conducted a retrospective cohort study at "Hospital de Campaña Escuela-Hogar" (HCEH) in Corrientes, Argentina, to assess safety and effectiveness of EPIC in hospitalized adults with severe COVID-19 pneumonia. Primary endpoints were 28-days all-cause mortality and safety. Mortality and improvement in modified WHO clinical scale at 14 and 21 days were secondary endpoints. Potential confounder adjustment was made by logistic regression weighted by the inverse of the probability of receiving the treatment (IPTW) and doubly robust approach. FINDINGS: Subsequent clinical records of 446 non-exposed (Controls) and 395 exposed (EPIC) patients admitted between November 2020 and April 2021 were analyzed. Median age was 58 years and 56.8% were males. Mortality at 28 days was 15.7% (EPIC) vs. 21.5% (Control). After IPTW adjustment the OR was 0.66 (95% CI: 0.46-0.96) P = 0.03. The effect was more evident in the subgroup who received two EPIC doses (complete treatment, n = 379), OR 0.58 (95% CI 0.39 to 0.85) P = 0.005. Overall and serious adverse events were not significantly different between groups. CONCLUSIONS: In this retrospective cohort study, EPIC showed adequate safety and effectiveness in the treatment of hospitalized patients with severe SARS-CoV-2 disease.

Análisis de causas de muerte intrahospitalarias mal definidas e imprecisas / Analysis of ill-defined and imprecise in-hospital causes of death

Introducción: la información sobre las causas de muerte es de gran importancia tanto para los países como para las instituciones sanitarias, en la medida en que contribuye a la evaluación y el seguimiento del estado de salud de la población y a la planificación de intervenciones sanitarias. El objetivo del estudio fue evaluar la proporción de causas de muerte mal definidas e imprecisas y su relación con el día de la semana y período lectivo de médicos residentes en el Hospital Italiano de Buenos Aires (HIBA) durante 2020. Métodos: se realizó un estudio analítico de corte transversal a partir de certificados médicos de defunción de pacientes fallecidos en el ámbito intrahospitalario, evaluando las causas de muerte mal definidas (términos médicos que no aportan información desde el punto de vista clínico y epidemiológico) y las imprecisas (no resultan lo suficientemente específicas como para identificar entidades nosológicas que permitan establecer acciones de prevención y control). Resultados: se analizaron 1030 certificados de defunción, con una proporción de certificados con causa básica de muerte mal definida del 2,3% (n = 24), mientras que en el 17,4% (n = 180) fue imprecisa. No se hallaron diferencias entre la proporción de causas básicas mal definidas y las imprecisas según el día de la semana o período lectivo. Al extender el análisis a todas las causas (básicas, mediatas e inmediatas), la proporción de causas mal definidas fue del 1,6% (n = 40) y la de imprecisas del 51% (n = 1212). Conclusiones: los resultados definen al HIBA como un centro de mediana calidad estadística en el registro de causas de muerte. Se concluye que es necesario mejorarla, para lo que resulta de interés la creación de un plan de capacitación y entrenamiento de los médicos en el grado y el posgrado. (AU)

Introduction: information on causes of death is of great importance both for countries and for health institutions, as it contributes to the evaluation and monitoring of the health status of the population and to the planning of health interventions. The purpose of this study was to evaluate the proportion of ill-defined and imprecise causes of death and its relationship with the day of the week and academic calendar during 2020 at the Hospital Italiano de Buenos Aires. Methods: a cross-sectional study was carried out from data recorded in the death certificates of patients who died in the intrahospital setting, evaluating ill-defined causes of death (medical terms that do not provide clinical or epidemiological information) and imprecise ones (not specific enough to identify nosological entities susceptible to prevention or control). Results: 1030 death certificates were analyzed. The proportion of certificates with ill-defined underlying causes of death was 2.3% (n=24), while 17.4% (n=180) was imprecise. No significant differences were found between the ill-defined and imprecise underlying causes of death and the day of the week and academic calendar. When extending the analysis to all causes (underlying, intermediate, and immediate) the percentage of ill-defined causes was 1.6% (n=40) and 51% (n=1212) was imprecise. Conclusions: results define our hospital as of medium statistical quality on medical death certification. It is concluded that it is necessary to improve the quality of the registry, for which the creation of a training plan for undergraduate and graduate physicians is of interest. (AU)

Aprendizaje automático aplicado en área de la salud: parte 2 / Machine Learning In Healthcare: part 2

En el artículo anterior se introdujo el tema y se desarrolló cómo es la recolección y análisis de datos, la selección y entrenamiento de modelos de aprendizaje automático supervisados y los métodos de validación interna que permiten corroborar si el modelo arroja resultados similares a los de otros conjuntos de entrenamiento y de prueba. En este artículo continuaremos con la descripción de la evaluación del rendimiento, la selección del modelo más adecuado para identificar la característica que se va a evaluar y la validación externa del modelo. Además, el artículo resume los desafíos existentes en la implementación del Machine Learning desde la investigación al uso clínico. (AU)

In the previous article, we introduced topics such as data collection and analysis, selection and training of supervised machine learning models and methods of internal validation that allow to corroborate whether the model yields similar results to other training and test sets.In this article, we will continue with the description of the performance evaluation, selecting the most appropriate model to identify the characteristic to evaluate and the external validation of the model. In addition, the article summarizes the actual challenges in the implementation of machine learning from research to clinical use. (AU)

Aprendizaje automático aplicado en área de la salud: parte 1 / Machine learning in healthcare: part 1

Este será el primero de dos artículos donde se tratarán los pasos necesarios para desarrollar un proyecto de aplicación de técnicas de Machine Learning en Salud, que introduce nociones sobre la recolección y análisis de datos, la selección y entrenamiento de modelos de aprendizaje auto-mático de tipo supervisado y los métodos de validación interna para cada modelo. (AU)

This will be the first of two articles where the steps needed to apply machine learning methods in healthcare will be discussed. It will introduce fundamental notions about data collection, selection and training of supervised ML models as well as the methods of internal validation. In a second article, we will discuss about the performance evaluation to select the most appropriate model and its external validation. (AU)

A Randomized Trial of Convalescent Plasma in Covid-19 Severe Pneumonia.

BACKGROUND: Convalescent plasma is frequently administered to patients with Covid-19 and has been reported, largely on the basis of observational data, to improve clinical outcomes. Minimal data are available from adequately powered randomized, controlled trials. METHODS: We randomly assigned hospitalized adult patients with severe Covid-19 pneumonia in a 2:1 ratio to receive convalescent plasma or placebo. The primary outcome was the patient's clinical status 30 days after the intervention, as measured on a six-point ordinal scale ranging from total recovery to death. RESULTS: A total of 228 patients were assigned to receive convalescent plasma and 105 to receive placebo. The median time from the onset of symptoms to enrollment in the trial was 8 days (interquartile range, 5 to 10), and hypoxemia was the most frequent severity criterion for enrollment. The infused convalescent plasma had a median titer of 1:3200 of total SARS-CoV-2 antibodies (interquartile range, 1:800 to 1:3200). No patients were lost to follow-up. At day 30 day, no significant difference was noted between the convalescent plasma group and the placebo group in the distribution of clinical outcomes according to the ordinal scale (odds ratio, 0.83; 95% confidence interval [CI], 0.52 to 1.35; P = 0.46). Overall mortality was 10.96% in the convalescent plasma group and 11.43% in the placebo group, for a risk difference of -0.46 percentage points (95% CI, -7.8 to 6.8). Total SARS-CoV-2 antibody titers tended to be higher in the convalescent plasma group at day 2 after the intervention. Adverse events and serious adverse events were similar in the two groups. CONCLUSIONS: No significant differences were observed in clinical status or overall mortality between patients treated with convalescent plasma and those who received placebo. (PlasmAr ClinicalTrials.gov number, NCT04383535.).

Effect of statins on development of post thrombotic syndrome: cohort study. / Efecto de las estatinas en el desarrollo de síndrome postrombótico: estudio de cohorte

Objetivo: Explorar la asociación entre consumo de estatinas (CE) y desarrollo de síndrome postrombótico (SPT). Método: Cohorte retrospectiva con pacientes con primer episodio de trombosis venosa profunda (TVP) entre el 06/2006 y el 12/2017, incluidos en el Registro Institucional de Enfermedad TromboEmbólica (RIET) del Hospital Italiano de Buenos Aires. Se consideró exposición al CE entre los 30 días previos y hasta 180 días posterior al diagnóstico de TVP. Se definió SPT según constaba este dato en la base de seguimiento del RIET. Se evaluó el desarrollo de SPT con un modelo de riesgos proporcionales de Cox, reportando hazard ratios (HR) crudas y ajustadas. Se consideró la confusión por indicación del CE y se utilizó un propensity score (PS) para el ajuste del riesgo estimado, reportando los HR con sus intervalos de confianza del 95% (IC 95%). Resultados: Se incluyeron 905 pacientes, de los cuales 273 fueron CE y 632 no consumidor de estatinas (NCE). Al seguimiento, la incidencia de SPT fue: 6.59% (18) en el grupo CE y 8.07% (51) en el grupo NCE, con p = 0.412. La razón de riesgo para el desarrollo de SPT de CE resultó no significativa (HR cruda: 0.78; IC 95%: 0.43-1.41; p = 0.414). La HR de CE ajustada por edad, sexo, antiinflamatorios no esteroideos, corticosteroides, inmovilidad, anticoagulante, hipertensión arterial, diabetes, dislipidemia, insuficiencia renal crónica, enfermedad coronaria, accidente cerebrovascular, insuficiencia cardiaca y enfermedad oncológica fue 0.45 (IC 95%: 0.13-1.5; p = 0.196). La HR del CE ajustado por edad, sexo, antiinflamatorios no esteroideos, corticosteroides, inmovilidad, tratamiento anticoagulante, enfermedad oncológica y PS fue de 0.52 (IC 95%: 0.17-1.66; p = 0.272). Conclusiones: El CE no se asoció con menor SPT, aunque hubo escaso número de eventos detectados. Objective: To evaluate the association between statin consumption and development of post-thrombotic syndrome (PTS). Methods: Retrospective cohort study which included patients with a first episode of deep vein thrombosis (DVT) between 06/2006 and 12/2017, included in the Institutional Registry of ThromboEmbolic Disease of the Italian Hospital of Buenos Aires, Argentina. Exposure to statin use (SU) was considered between the 30 days before and up to 180 days after the diagnosis of DVT. PTS was defined as recorded dataset on registry. The development of PTS was evaluated with Cox proportional hazards model, raw and adjusted hazard ratios (HR) were reported. Confusion was considered by indication of SU and a propensity score (PS) was used for adjustment. We reported HR with their 95% confidence interval (CI); p value < 0.05 was considered statistically significant. Results: Of 1393 patients, 905 were included for the analysis, of which 273 were SU and 632 non-statin users (NSU). At follow-up, incidence of PTS was: 6.59% (18) in the SU group and 8.07% (51) in the NSU group, with p = 0.412. Crude HR for PTS for SU was not significant (0.78; 95% CI: 0.43-1.41; p = 0.414). Adjusted HR of SU by age, sex, non-steroidal anti-inflammatory drugs, corticosteroids, immobility, anticoagulant, high blood pressure, diabetes, dyslipidemia, chronic renal failure, coronary heart disease, stroke, heart failure and cancer disease was 0.45 (95% CI: 0.13-1.5; p = 0.196) for PTS. While HR for the development of PTS adjusted by age, sex, non-steroidal anti-inflammatory drugs, corticosteroids, immobility, anticoagulant treatment, cancer disease and PS of the SU was 0.52 (95% CI: 0.17-1.66; p = 0.272). Conclusion: No statistically significant association was found between CE and the development of SPT, although there were a small number of events detected in both groups.

Efecto de las estatinas en el desarrollo de síndrome postrombótico: estudio de cohorte / Effect of statins on development of post thrombotic syndrome: cohort study

Resumen Objetivo: Explorar la asociación entre consumo de estatinas (CE) y desarrollo de síndrome postrombótico (SPT). Método: Cohorte retrospectiva con pacientes con primer episodio de trombosis venosa profunda (TVP) entre el 06/2006 y el 12/2017, incluidos en el Registro Institucional de Enfermedad TromboEmbólica (RIET) del Hospital Italiano de Buenos Aires. Se consideró exposición al CE entre los 30 días previos y hasta 180 días posterior al diagnóstico de TVP. Se definió SPT según constaba este dato en la base de seguimiento del RIET. Se evaluó el desarrollo de SPT con un modelo de riesgos proporcionales de Cox, reportando hazard ratios (HR) crudas y ajustadas. Se consideró la confusión por indicación del CE y se utilizó un propensity score (PS) para el ajuste del riesgo estimado, reportando los HR con sus intervalos de confianza del 95% (IC 95%). Resultados: Se incluyeron 905 pacientes, de los cuales 273 fueron CE y 632 no consumidor de estatinas (NCE). Al seguimiento, la incidencia de SPT fue: 6.59% (18) en el grupo CE y 8.07% (51) en el grupo NCE, con p = 0.412. La razón de riesgo para el desarrollo de SPT de CE resultó no significativa (HR cruda: 0.78; IC 95%: 0.43-1.41; p = 0.414). La HR de CE ajustada por edad, sexo, antiinflamatorios no esteroideos, corticosteroides, inmovilidad, anticoagulante, hipertensión arterial, diabetes, dislipidemia, insuficiencia renal crónica, enfermedad coronaria, accidente cerebrovascular, insuficiencia cardiaca y enfermedad oncológica fue 0.45 (IC 95%: 0.13-1.5; p = 0.196). La HR del CE ajustado por edad, sexo, antiinflamatorios no esteroideos, corticosteroides, inmovilidad, tratamiento anticoagulante, enfermedad oncológica y PS fue de 0.52 (IC 95%: 0.17-1.66; p = 0.272). Conclusiones: El CE no se asoció con menor SPT, aunque hubo escaso número de eventos detectados.

Abstract Objective: To evaluate the association between statin consumption and development of post-thrombotic syndrome (PTS). Methods: Retrospective cohort study which included patients with a first episode of deep vein thrombosis (DVT) between 06/2006 and 12/2017, included in the Institutional Registry of ThromboEmbolic Disease of the Italian Hospital of Buenos Aires, Argentina. Exposure to statin use (SU) was considered between the 30 days before and up to 180 days after the diagnosis of DVT. PTS was defined as recorded dataset on registry. The development of PTS was evaluated with Cox proportional hazards model, raw and adjusted hazard ratios (HR) were reported. Confusion was considered by indication of SU and a propensity score (PS) was used for adjustment. We reported HR with their 95% confidence interval (CI); p value < 0.05 was considered statistically significant. Results: Of 1393 patients, 905 were included for the analysis, of which 273 were SU and 632 non-statin users (NSU). At follow-up, incidence of PTS was: 6.59% (18) in the SU group and 8.07% (51) in the NSU group, with p = 0.412. Crude HR for PTS for SU was not significant (0.78; 95% CI: 0.43-1.41; p = 0.414). Adjusted HR of SU by age, sex, non-steroidal anti-inflammatory drugs, corticosteroids, immobility, anticoagulant, high blood pressure, diabetes, dyslipidemia, chronic renal failure, coronary heart disease, stroke, heart failure and cancer disease was 0.45 (95% CI: 0.13-1.5; p = 0.196) for PTS. While HR for the development of PTS adjusted by age, sex, non-steroidal anti-inflammatory drugs, corticosteroids, immobility, anticoagulant treatment, cancer disease and PS of the SU was 0.52 (95% CI: 0.17-1.66; p = 0.272). Conclusion: No statistically significant association was found between CE and the development of SPT, although there were a small number of events detected in both groups.

The tobacco epidemic curve in Brazil: Where are we going?

BACKGROUND: Brazil experienced a robust decline in smoking prevalence rates as a consequence of public policies. Since lung cancer is strongly associated with smoking, trends in lung cancer mortality rates may be used as a delayed effectiveness indicator of smoking prevention interventions. OBJECTIVES: The aim of this study was to estimate lung cancer mortality trends from 1980 through 2017 and to predict temporal trends in lung cancer mortality rates, in Brazil from 2016 through 2040. METHODS: Time trends in lung cancer mortality rates were evaluated using data from available public databases. Crude and age-standardized mortality rates were calculated for each year sex-specific mortality predictions were made for each five-year period from 2016 to 2020 through 2036-2040 using an age-period-cohort (APC) model. Sex ratios were estimated using age-standardized lung cancer mortality rates. RESULTS: A decline in age-standardized lung cancer mortality rates has been observed for males since 2005 and for all predicted periods. It is expected that females aged 55 or younger will experience a reduction in lung cancer mortality from 2021 to 2026 onwards, but for those aged 75 or over rates are predicted to continue increasing through 2036-2040. CONCLUSION: Smoking prevention and cessation policies are essential, and it is important to commit to an ethical framework whereby equity in tobacco control activities between genders is achieved. This will avert many premature and preventable smoking-related deaths in the next decades.

Enfoque de género en las residencias médicas de un hospital universitario / Gender approach in medical residences of a university hospital

Se observa un proceso de feminización de la profesión médica, sin embargo, el acceso masivo de las mujeres se asocia a nuevas desigualdades de género, denominadas segregación horizontal y vertical. La segregación horizontal se manifiesta en la desigual distribución de hombres y mujeres en ciertas especialidades médicas y la segregación vertical, en la escasa representación de las mujeres en la mayoría de los altos cargos profesionales. El objetivo de este estudio fue determinar cómo se distribuyen hombres y mujeres en las distintas instancias del proceso que implica el ingreso al sistema de residencias médicas de un hospital universitario de Buenos Aires, Argentina y analizar la segregación horizontal y vertical de género en el proceso de ingreso a las residencias médicas. A partir de datos de postulantes a un hospital universitario, en el período 2015-2017, se realizó un análisis de regresión logística múltiple para ajustar el odds ratio de ser hombre o mujer con potenciales confundidores. No se observó asociación entre ser hombre o mujer y la realización del examen, su aprobación y el ingreso a entrevista. El odds ratio ajustado para el ingreso a la residencia de los hombres con respecto a las mujeres fue 2.03 (1.44-2.85). Para las residencias quirúrgicas fue 2.75 (1.54-4.92) y para las clínicas fue 1.89 (1.17-3.00). En la inscripción, las mujeres optaron mayormente por residencias clínicas, y los hombres por quirúrgicas. Se observó segregación horizontal y vertical en el proceso de ingreso a la residencia. Visibilizar la segregación de género permitirá generar una sociedad equitativa.

A process of feminization of the medical profession is observed, however, the massive access of women is associated with new gender inequalities named horizontal and vertical segregation. Horizontal segregation manifests itself in the unequal distribution of men and women in certain medical specialties and vertical segregation, in the limited representation of women in most high professional positions. The objective of this study was to determine how men and women are distributed in the different stages of the process that involves entering the medical residency system of an universitary hospital from Buenos Aires, Argentina, and to analyze the horizontal and vertical segregation of gender in the process of admission to medical residencies. Based on data from applicants to an universitary hospital, in the 2015-2017 period, a multiple logistic regression analysis was conducted to adjust the odds ratio of being male or female with potential confounders. There was no association between being man or woman and the performance of the exam, its approval and the admission to the interview. The adjusted odds ratio for the admission to the residency of men with respect to women was 2.03 (1.44-2.85). For the surgical residencies it was 2.75 (1.54-4.92) and for clinical it was 1.89 (1.17-3.00). In the inscription, women opted mainly for clinical residencies, and men for surgical purposes. Horizontal and vertical segregation was observed in the process of the residency. Making gender segregation visible will allow generating an equitable society.

[Gender approach in medical residences of a university hospital]. / Enfoque de género en las residencias médicas de un hospital universitario.

A process of feminization of the medical profession is observed, however, the massive access of women is associated with new gender inequalities named horizontal and vertical segregation. Horizontal segregation manifests itself in the unequal distribution of men and women in certain medical specialties and vertical segregation, in the limited representation of women in most high professional positions. The objective of this study was to determine how men and women are distributed in the different stages of the process that involves entering the medical residency system of an universitary hospital from Buenos Aires, Argentina, and to analyze the horizontal and vertical segregation of gender in the process of admission to medical residencies. Based on data from applicants to an universitary hospital, in the 2015-2017 period, a multiple logistic regression analysis was conducted to adjust the odds ratio of being male or female with potential confounders. There was no association between being man or woman and the performance of the exam, its approval and the admission to the interview. The adjusted odds ratio for the admission to the residency of men with respect to women was 2.03 (1.44-2.85). For the surgical residencies it was 2.75 (1.54-4.92) and for clinical it was 1.89 (1.17-3.00). In the inscription, women opted mainly for clinical residencies, and men for surgical purposes. Horizontal and vertical segregation was observed in the process of the residency. Making gender segregation visible will allow generating an equitable society.

Se observa un proceso de feminización de la profesión médica, sin embargo, el acceso masivo de las mujeres se asocia a nuevas desigualdades de género, denominadas segregación horizontal y vertical. La segregación horizontal se manifiesta en la desigual distribución de hombres y mujeres en ciertas especialidades médicas y la segregación vertical, en la escasa representación de las mujeres en la mayoría de los altos cargos profesionales. El objetivo de este estudio fue determinar cómo se distribuyen hombres y mujeres en las distintas instancias del proceso que implica el ingreso al sistema de residencias médicas de un hospital universitario de Buenos Aires, Argentina y analizar la segregación horizontal y vertical de género en el proceso de ingreso a las residencias médicas. A partir de datos de postulantes a un hospital universitario, en el período 2015-2017, se realizó un análisis de regresión logística múltiple para ajustar el odds ratio de ser hombre o mujer con potenciales confundidores. No se observó asociación entre ser hombre o mujer y la realización del examen, su aprobación y el ingreso a entrevista. El odds ratio ajustado para el ingreso a la residencia de los hombres con respecto a las mujeres fue 2.03 (1.44-2.85). Para las residencias quirúrgicas fue 2.75 (1.54-4.92) y para las clínicas fue 1.89 (1.17-3.00). En la inscripción, las mujeres optaron mayormente por residencias clínicas, y los hombres por quirúrgicas. Se observó segregación horizontal y vertical en el proceso de ingreso a la residencia. Visibilizar la segregación de género permitirá generar una sociedad equitativa.

[AA amyloidosis. A single institution cohort study]. / Amiloidosis AA. Estudio de cohorte en una institución.

There is limited epidemiological information on AA amyloidosis in Argentina, so the objective of this study was to describe the epidemiological characteristics of this disease in a tertiary hospital in our country. We designed a prospective clinical cohort of all consecutive patients with AA amyloidosis confirmed by immunohistochemistry in tissue from the Institutional Registry of Amyloidosis of the Hospital Italiano de Buenos Aires, in the period 04/01/2012- 12/31/2017. Of the 121 patients in the registry, 18 were included with AA for the analysis. Of the total included, 50% (9) were female, with a median age of 53.5 (interquartile range, RII 46-61) years. The 88.9% (16) of cohort presented renal compromise, all had proteinuria, and 6 required dialysis. Six had amyloid infiltration of the digestive system. The latency between the onset of the underlying disease and the diagnosis of AA had a median of 27 (RII 8-35) years. The underlying disease was of inflammatory origin in 6 cases. In 50% (9) of the patients the cause of AA amyloidosis was unknown. In the remaining 50%, these causes resemble those observed in developed countries. Furthermore, our results highlight the importance of their differential diagnosis to identify the most appropriate treatment or follow-up according to the situation presented by each patient.

La amiloidosis AA causa principalmente disfunción renal, lo que lleva a un elevado riesgo de mortalidad a mediano plazo. Existe escasa información epidemiológica sobre la amiloidosis AA en Argentina, por lo que el objetivo de este trabajo fue describir las características epidemiológicas de esta enfermedad en un hospital de tercer nivel en nuestro país. Se realizó una cohorte prospectiva de todos los pacientes consecutivos con evidencia de amiloidosis AA, por inmunohistoquímica de tejidos, incluidos en el Registro Institucional de Amiloidosis del Hospital Italiano de Buenos Aires, desde el 01/04/2012 hasta el 31/12/2017. De los 121 pacientes del registro, se incluyeron 18 con AA para el análisis. Del total incluido, 50% (9) eran mujeres, con una mediana de edad de 53.5 (rango intercuartil, RII 46-61) años. El 88.9% (16) presentó compromiso renal, todos tuvieron proteinuria, y 6 requirieron diálisis. Seis tuvieron infiltración amiloide del aparato digestivo. La latencia entre la aparición de la enfermedad subyacente y el diagnóstico de AA tuvo una mediana de 27 (RII 8-35) años. La enfermedad subyacente fue de origen inflamatorio en 6 casos. En el 50% (9) de los enfermos la causa de amiloidosis AA fue desconocida. En el restante 50% esas causas se asemejan a las de países desarrollados. A su vez, nuestros resultados resaltan la importancia de su diagnóstico diferencial para identificar el tratamiento o seguimiento más adecuado según el cuadro que presente cada paciente.

Amiloidosis AA: Estudio de cohorte en una institución / AA amyloidosis. A single institution cohort study

La amiloidosis AA causa principalmente disfunción renal, lo que lleva a un elevado riesgo de mortalidad a mediano plazo. Existe escasa información epidemiológica sobre la amiloidosis AA en Argentina, por lo que el objetivo de este trabajo fue describir las características epidemiológicas de esta enfermedad en un hospital de tercer nivel en nuestro país. Se realizó una cohorte prospectiva de todos los pacientes consecutivos con evidencia de amiloidosis AA, por inmunohistoquímica de tejidos, incluidos en el Registro Institucional de Amiloidosis del Hospital Italiano de Buenos Aires, desde el 01/04/2012 hasta el 31/12/2017. De los 121 pacientes del registro, se incluyeron 18 con AA para el análisis. Del total incluido, 50% (9) eran mujeres, con una mediana de edad de 53.5 (rango intercuartil, RII 46-61) años. El 88.9% (16) presentó compromiso renal, todos tuvieron proteinuria, y 6 requirieron diálisis. Seis tuvieron infiltración amiloide del aparato digestivo. La latencia entre la aparición de la enfermedad subyacente y el diagnóstico de AA tuvo una mediana de 27 (RII 8-35) años. La enfermedad subyacente fue de origen inflamatorio en 6 casos. En el 50% (9) de los enfermos la causa de amiloidosis AA fue desconocida. En el restante 50% esas causas se asemejan a las de países desarrollados. A su vez, nuestros resultados resaltan la importancia de su diagnóstico diferencial para identificar el tratamiento o seguimiento más adecuado según el cuadro que presente cada paciente.

There is limited epidemiological information on AA amyloidosis in Argentina, so the objective of this study was to describe the epidemiological characteristics of this disease in a tertiary hospital in our country. We designed a prospective clinical cohort of all consecutive patients with AA amyloidosis confirmed by immunohistochemistry in tissue from the Institutional Registry of Amyloidosis of the Hospital Italiano de Buenos Aires, in the period 04/01/2012- 12/31/2017. Of the 121 patients in the registry, 18 were included with AA for the analysis. Of the total included, 50% (9) were female, with a median age of 53.5 (interquartile range, RII 46-61) years. The 88.9% (16) of cohort presented renal compromise, all had proteinuria, and 6 required dialysis. Six had amyloid infiltration of the digestive system. The latency between the onset of the underlying disease and the diagnosis of AA had a median of 27 (RII 8-35) years. The underlying disease was of inflammatory origin in 6 cases. In 50% (9) of the patients the cause of AA amyloidosis was unknown. In the remaining 50%, these causes resemble those observed in developed countries. Furthermore, our results highlight the importance of their differential diagnosis to identify the most appropriate treatment or follow-up according to the situation presented by each patient.

Mean platelet volume as a prognostic factor for venous thromboembolic disease.

BACKGROUND: Mean platelet volume (MPV) is a risk factor for cardiovascular and inflammatory diseases. AIM: To evaluate the association between high MPV and 90-day mortality after an episode of venous thromboembolism (VTE). MATERIAL AND METHODS: Retrospective cohort of 594 patients with a median age of 73 years (58% women) with a first episode VTE, included in an institutional Thromboembolic Disease registry between 2014 and 2015. MPV values were obtained from the automated blood cell count measured at the moment of VTE diagnosis. Volumes ≥ 11 fL were classified as high. All patients were followed for 90 days to assess survival. RESULTS: The main comorbidities were cancer in 221 patients (37%), sepsis in 172 (29%) and coronary artery disease in 107 (18%). Median MPV was 8 fl (8-9), brain natriuretic peptide 2,000 pg/ml (1,025-3,900) and troponin 40 pg/ml (19.5-75). Overall mortality was 20% (121/594) during the 90 days of follow-up. Thirty three deaths occurred within 7 days and 43 within the first month. The loss of patients from follow-up was 5% (28/594) at 90 days. Mortality among patients with high MP was 36% (23/63). The crude mortality hazard ratio (HR) for high MPV was 2.2 (95% confidence intervals (CI) 1.4-3.5). When adjusted for sepsis, oncological disease, heart disease, kidney failure and surgery, the mortality HR of high MPV was 2.4 (CI95% 1.5-3.9) in the VTE group, 2.3 (CI95% 1.5-4.4) in the deep venous thrombosis group, and 2.9 (CI95% 1.6 -5.6) in the pulmonary embolism group. CONCLUSIONS: High MPV is an independent risk factor for mortality following an episode of VTE.

Mean platelet volume as a prognostic factor for venous thromboembolic disease / Volumen plaquetario medio como factor pronóstico de la enfermedad tromboembólica venosa

ABSTRACT Background: Mean platelet volume (MPV) is a risk factor for cardiovascular and inflammatory diseases. Aim: To evaluate the association between high MPV and 90-day mortality after an episode of venous thromboembolism (VTE). Material and Methods: Retrospective cohort of 594 patients with a median age of 73 years (58% women) with a first episode VTE, included in an institutional Thromboembolic Disease registry between 2014 and 2015. MPV values were obtained from the automated blood cell count measured at the moment of VTE diagnosis. Volumes ≥ 11 fL were classified as high. All patients were followed for 90 days to assess survival. Results: The main comorbidities were cancer in 221 patients (37%), sepsis in 172 (29%) and coronary artery disease in 107 (18%). Median MPV was 8 fl (8-9), brain natriuretic peptide 2,000 pg/ml (1,025-3,900) and troponin 40 pg/ml (19.5-75). Overall mortality was 20% (121/594) during the 90 days of follow-up. Thirty three deaths occurred within 7 days and 43 within the first month. The loss of patients from follow-up was 5% (28/594) at 90 days. Mortality among patients with high MP was 36% (23/63). The crude mortality hazard ratio (HR) for high MPV was 2.2 (95% confidence intervals (CI) 1.4-3.5). When adjusted for sepsis, oncological disease, heart disease, kidney failure and surgery, the mortality HR of high MPV was 2.4 (CI95% 1.5-3.9) in the VTE group, 2.3 (CI95% 1.5-4.4) in the deep venous thrombosis group, and 2.9 (CI95% 1.6 −5.6) in the pulmonary embolism group. Conclusions: High MPV is an independent risk factor for mortality following an episode of VTE.

Antecedentes: El volumen plaquetario medio (VPM) es un factor de riesgo de complicaciones cardiovasculares y enfermedades inflamatorias. Objetivo: Evaluar la asociación entre VPM alto y la mortalidad a los 90 días después de un episodio de tromboembolismo venoso (ETV). Material y Métodos: Cohorte retrospectiva de 594 pacientes adultos con una edad media de 73 años (58% mujeres) con un primer episodio de ETV incluidos en un registro de enfermedad tromboembólica institucional entre 2014 y 2015. Se obtuvieron valores de VPM desde el hemograma tomado en el momento del diagnóstico de ETV y un volumen ≥ 11 fL fue clasificado como alto. Todos los pacientes fueron seguidos durante 90 días para determinar sobrevida. Resultados: Las comorbilidades fueron cáncer en 221 pacientes (37%), sepsis en 172 (29%) y enfermedad coronaria en 107 (18%). La mediana de VPM fue 8 fl (89), el péptido natriurético cerebral fue de 2.000 pg/ml (1.025-3.900) y la troponina fue de 40 pg/ml (19,5-75). La mortalidad global a 90 días fue 20% (121/594). Treinta y tres muertes ocurrieron dentro de los 7 días y 43 en el primer mes. La pérdida de seguimiento de pacientes fue de 5% (28/594) a los 90 días. La mortalidad en el grupo con VPM alto fue 36% (23/63). La razón de riesgo (HR) cruda de la mortalidad para un VPM alto fue de 2,2 (intervalos de confianza (IC) de 95% 1,4-3,5). Cuando se ajustó por sepsis, enfermedad oncológica, enfermedad cardíaca, insuficiencia renal y cirugía, la HR de muerte para un VPM alto fue de 2,4 (IC95% 1,5-3,9) en el grupo de ETV; 2,3 (IC95% 1,5-4,4) en el grupo de trombosis venosa profunda; y 2,9 (CI95% 1,6 −5,6) en el grupo de embolia pulmonar. Conclusiones: Un VPM alto es un factor de riesgo independiente de mortalidad después de un episodio de ETV.

Comparing Office, Central, Home and Ambulatory Blood Pressure in Predicting Left Ventricular Mass.

The blood pressure measurement method that more accurately predicts a left ventricular mass is controversial, and the evidence suggesting superiority of central over brachial measurements is contradictory. The aim of this study was to compare the relationship between the different clinic and out-of-clinic blood pressure measurements methods with left ventricular mass in patients who attended a specialised hypertension centre for a central blood pressure measurement. An analysis was performed on the correlations between left ventricular mass and central and brachial blood pressure measurements made in the clinic, and home, as well as 24-h systolic blood pressure measurements. A linear regression analysis was then performed to assess the independent relationship of each blood pressure measurement with left ventricular mass. The results on 824 treated and 123 untreated patients showed no significant differences between correlations, although home readings tended to have the best correlations. In regression adjusted models, for each 10 mmHg increase in systolic home blood pressure the left ventricular mass increased 10 g/m2 (95% CI; 3.7-27, p=.01, adjR2 0.38), and for 24-h ambulatory systolic blood pressure it increased 2.3 g/m2 (95% CI 0.76-3.9, p<.01, adjR2 0.15) in treated and untreated patients, respectively. The association of systolic blood pressure with left ventricular mass was better explained by home and 24-h ambulatory monitoring than to clinic-based measurements in treated and untreated patients, respectively. In the clinic, however, the central measurement was not superior to brachial blood pressure.