Prevalence of incidental clinically relevant pancreatic cysts at diagnosis based on current guidelines.

BACKGROUND: Most pancreatic cysts (PCs) found incidentally by CT and MRI scans might not be clinically important according to the Fukuoka guidelines, the American Gastroenterological Association (AGA) guidelines and European guidelines. AIMS: To determine and compare the prevalence of incidental clinically important PCs (CIPCs). METHODS: Abdominal contrast-enhanced CT or MRI scans performed during a one-year period were retrospectively reviewed to identify incidental PCs. CIPCs were defined as those cysts that would be capable of triggering further evaluation with endoscopic ultrasound, immediate surveillance (within 3-6 months) and/or surgery. Prevalence was calculated as the number of patients with CIPCs per 100 subjects imaged (%). RESULTS: Sixty patients (mean age 70±14 years) out of 565 were found to have incidental PCs, representing a prevalence of 8.7% (95% CI 6.3-11.5) in CT scans and 27.5% (95% CI 16-41) in MRI scans. Seven patients (11.6%, 95% CI 5-22) had CIPCs based on size ≥ 30mm (n=5), size ≥ 30mm and pancreatic duct (PD) dilation (n=1) and PD dilation and presence of solid component (n=1). Based on the Fukuoka guidelines, the prevalence of CIPCs was 1.2% (95% CI 0.4-2.5) in CT scans (6/507) and 1.7% (95% CI 0.1-9) in MRI scans (1/58). Based on the AGA and European guidelines, the prevalence of CIPCs was 0.2% (95% CI 0.1-1) in CT scans (1/507) and 1.7% (95% CI 0.1-9) in MRI scans (1/58). Patients with PCs initially classified as "AGA- or European-positive" had a higher surgical probability and this decision was taken earlier in the follow-up. CONCLUSIONS: In our cohort, the prevalence of important incidental pancreatic cysts was not negligible at around 1% according to current guidelines.

[Primary epiploic appendagitis: clinical features in 73 cases]. / Apendagitis epiploica primaria. Clínica y evolución de 73 casos.

Primary epiploic appendagitis is a relatively rare disease in the differential diagnosis of acute abdomen, nonetheless it is an entity that should not be ignored by physicians and surgeons in order to prevent unnecessary interventions and overuse of antibiotics. To substantiate this concept a search was conducted at the Hospital Aleman, Buenos Aires between April 2007 and July 2013. The aim was clinical histories containing sonographic and tomographic images with diagnosis of omental appendagitis; and subsequently their electronic medical records were reviewed. The clinical features and outcome of a case series of 73 primary omental appendagitis were selected; the mean age was 45 years (± 16); 54 (74%) were men. Abdominal pain (left lower quadrant in 89% of cases) was the most common symptom. Abdominal ultrasound was performed on 44 (60%) of patients, computed tomography on 21 (29%), and both studies on 8 (11%) of cases in this series. In 49% of cases surgery consultation was requested. Fifteen patients (21%) were treated with antibiotics, 73% of them were prescribed by a clinician. Sixty seven patients (92%) were treated as outpatients with non steroidal anti-inflammatory drugs (NSAIDs); two required laparoscopic surgery, two required hospitalization and two others were treated with opioids. Epiploic apendagitis is uncommon in the differential diagnosis of acute abdomen, but is an entity that should not be ignored by physicians to prevent unnecessary interventions and overuse of antibiotics.

PULSE-HF: A Simple Clinical and Geriatric Score to Predict Systolic Dysfunction in the Elderly Without Heart Failure.

To develop a clinical score to determine preclinical predictors of systolic dysfunction in an outpatient elderly population without a diagnosis of heart failure (HF). PULSE-HF is a cross-sectional study in elderly at-risk (coronary artery disease, diabetes or hypertension) outpatients without a diagnosis of heart failure (HF). The objective in this population was to develop a clinical score to determine preclinical predictors of systolic dysfunction. Clinical and geriatric variables were analyzed; independent predictive factors in the logistic regression analysis were included for the score calculation. Of the 722 subjects enrolled, 47 (6.5%) had a left ventricular ejection fraction (LVEF) < 50%, and 15 (2.1%) a LVEF < 40%. Mean age was 76.5 years (5.18) and 445 (61.6%) were female. Multiple logistic regression analysis identified abnormal Q waves (odds ratio [OR]: 4.36; P = 0.003), cardiomegaly (OR: 3.32; P < 0.001), right bundle branch block (OR: 2.84; P = 0.011), cognitive dysfunction (OR: 2.14; P = 0.027) and NT-proBNP (OR 5.43; P < 0.001) as independent predictors of LVEF < 50%. Two prediction scores were built, without and with NT-proBNP inclusion; the area under ROC curves were 0.70 and 0.76, respectively. As the score increased, the sensitivity decreases but increases specificity, and accuracy (97.17% and 91.64% respectively in ≥6 points). NT-proBNP was associated with an increment in the performance (accuracy of 93.18% for score ≥10). We conclude that a simple score using clinical information might be useful to predicting asymptomatic systolic dysfunction in the elderly.

Impact of facilitating physician access to relevant medical literature on outcomes of hospitalised internal medicine patients: a randomised controlled trial.

INTRODUCTION: There is limited high-quality evidence regarding the usefulness of bibliographic assistance in improving clinically important outcomes in hospitalised patients. This study was designed to evaluate the impact of providing attending physicians with bibliographic information to assist them in answering medical questions that arise during daily clinical practice. METHODS: All patients admitted to the Internal Medicine ward of Hospital Aleman in Buenos Aires between March and August 2010 were randomly assigned to one of two groups: intervention or control. Throughout this period, the medical questions that arose during morning rounds were identified. Bibliographic research was conducted to answer only those questions that emerged during the discussion of patients assigned to the intervention group. The compiled information was sent via e-mail to all members of the medical team. RESULTS: 809 patients were included in the study, 407 were randomly assigned to a search-supported group and 402 to a control group. There was no significant difference in death or transfer to an intensive care unit (ICU) (RR 1.09 (95% CI 0.7 to 1.6)), rehospitalisation (RR 1.0 (95% CI 0.7 to 1.3)) or length of hospitalisation (6.5 vs 6.0 days, p=0.25). The subgroup of search-supported physicians' patients (n=31), whose attending physicians received hand-delivered information, had a significantly lower risk of death or transfer to an ICU compared with the control group (0% vs 13.7%, p=0.03). CONCLUSIONS: The impact of bibliographic assistance on clinically important outcomes could not be proven by this study. However, results suggest that some interventions, such as delivering information by hand, might be beneficial in a subgroup of inpatients.

Automatic Detection of Vital Signs in Clinical Notes of the Outpatient Settings.

The determination of vital signs is a fundamental aspect of patient care. Electronic health records have a structured format for their registration. It is known that the frequency with which this data is recollected is not representative of reality. To complement the missing data we have created a tool that extract the information regarding blood pressure, heart rate, respiratory rate, height, weight and pain level recorded in free text in the clinical notes of outpatients.

Answering medical questions at the point of care: a cross-sectional study comparing rapid decisions based on PubMed and Epistemonikos searches with evidence-based recommendations developed with the GRADE approach.

INTRODUCTION: Using the best current evidence to inform clinical decisions remains a challenge for clinicians. Given the scarcity of trustworthy clinical practice guidelines providing recommendations to answer clinicians' daily questions, clinical decision support systems (ie, assistance in question identification and answering) emerge as an attractive alternative. The trustworthiness of the recommendations achieved by such systems is unknown. OBJECTIVE: To evaluate the trustworthiness of a question identification and answering system that delivers timely recommendations. DESIGN: Cross-sectional study. METHODS: We compared the responses to 100 clinical questions related to inpatient management provided by two rapid response methods with 'Gold Standard' recommendations. One of the rapid methods was based on PubMed and the other on Epistemonikos database. We defined our 'Gold Standard' as trustworthy published evidence-based recommendations or, when unavailable, recommendations developed locally by a panel of six clinicians following the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Recommendations provided by the rapid strategies were classified as potentially misleading or reasonable. We also determined if the potentially misleading recommendations could have been avoided with the appropriate implementation of searching and evidence summary tools. RESULTS: We were able to answer all of the 100 questions with both rapid methods. Of the 200 recommendations obtained, 6.5% (95% CI 3% to 9.9%) were classified as potentially misleading and 93.5% (95% CI 90% to 96.9%) as reasonable. 6 of the 13 potentially misleading recommendations could have been avoided by the appropriate usage of the Epistemonikos matrix tool or by constructing summary of findings tables. No significant differences were observed between the evaluated rapid response methods. CONCLUSION: A question answering service based on the GRADE approach proved feasible to implement and provided appropriate guidance for most identified questions. Our approach could help stakeholders in charge of managing resources and defining policies for patient care to improve evidence-based decision-making in an efficient and feasible manner.

Midodrine for orthostatic hypotension and recurrent reflex syncope: A systematic review.

OBJECTIVE: Symptomatic orthostatic hypotension (SOH) and recurrent reflex syncope (RRS) can be disabling. Midodrine has been proposed in the management of patients with these conditions but its impact on patient important outcomes remains uncertain. We performed a systematic review to evaluate the efficacy and safety of midodrine in patients with SOH and RRS. METHODS: We searched multiple electronic databases without language restriction from their inception to June 2013. We included randomized controlled trials of patients with SOH or RRS that compared treatment with midodrine against a control and reported data on patient important outcomes. We graded the quality of evidence according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. RESULTS: Eleven trials involving 593 patients were included in this review. Three studies addressed health-related quality of life in patients with RRS, showing improvement with midodrine: risk difference 14% (95% confidence interval [CI] -3.5 to 31.6), very low confidence. Seven studies addressed symptom improvement and provided poolable data showing improvement with midodrine in patients with SOH: risk difference 32.8% (95% CI 13.5-48), low confidence; and RRS: risk difference 63.3% (95% CI 47.6-68.2), very low confidence. Five studies reported syncope recurrence in patients with RRS showing improvement with midodrine: risk difference 37% (95% CI 20.8%-47.4%), moderate confidence. The most frequent side effects in the midodrine arm were pilomotor reactions (33.6%, risk ratio 4.58 [95% CI 2.03-10.37]). CONCLUSIONS: Evidence warranting low/moderate confidence suggests that midodrine improves clinical important outcomes in patients with SOH and RRS.

Efficacy and safety of finasteride therapy for androgenetic alopecia: a systematic review.

CONTEXT: Androgenetic alopecia is the most common form of alopecia in men. OBJECTIVE: To determine the efficacy and safety of finasteride therapy for patients with androgenetic alopecia. DATA SOURCES: MEDLINE, EMBASE, CINAHL, Cochrane Registers, and LILACS were searched for randomized controlled trials reported in any language that evaluated the efficacy and safety of finasteride therapy in comparison to treatment with placebo in adults with androgenetic alopecia. STUDY SELECTION AND DATA EXTRACTION: Two reviewers independently evaluated eligibility and collected the data, including assessment of methodological quality (Jadad score). Outcome measures included patient self-assessment, hair count, investigator clinical assessment, global photographic assessment, and adverse effects at short term (≤12 months) and long term (≥24 months). Heterogeneity was explored by testing a priori hypotheses. DATA SYNTHESIS: Twelve studies fulfilled the eligibility criteria (3927 male patients), 10 of which demonstrated a Jadad score of 3 or more. The proportion of patients reporting an improvement in scalp hair was greater with finasteride therapy than with placebo treatment in the short term (relative risk [RR], 1.81 [95% confidence interval (CI), 1.42-2.32]; I², 64%) and in the long term (RR, 1.71 [95% CI, 1.15-2.53]; I², 16%); both results were considered to have moderate-quality evidence. The number needed to treat for 1 patient to perceive himself as improved was 5.6 (95% CI, 4.6-7.0) in the short term and 3.4 (95% CI, 2.6-5.1) in the long term. Moderate-quality evidence suggested that finasteride therapy increased the mean hair count from baseline in comparison to placebo treatment, expressed as a percentage of the initial count in each individual, at short term (mean difference [MD], 9.42% [95% CI, 7.95%-10.90%]; I², 50%) and at long term (MD, 24.3% [95% CI, 17.92%-30.60%]; I², 0%). Also, the proportion of patients reported as improved by investigator assessment was greater in the short term (RR, 1.80 [95% CI, 1.43-2.26]; number needed to treat, 3.7 [95% CI, 3.2-4.3]; I², 82%) (moderate-quality evidence). Moderate-quality evidence suggested an increase in erectile dysfunction (RR, 2.22 [95% CI, 1.03-4.78]; I², 1%; number needed to harm, 82.1 [95% CI, 56-231]) and a possible increase in the risk of any sexual disturbances (RR, 1.39 [95% CI, 0.99-1.95]; I², 0%). The risk of discontinuing treatment because of sexual adverse effects was similar to that of placebo (RR, 0.88 [95% CI, 0.51-1.49]; I², 5%) (moderate-quality evidence). CONCLUSION: Moderate-quality evidence suggests that daily use of oral finasteride increases hair count and improves patient and investigator assessment of hair appearance, while increasing the risk of sexual dysfunction.

Apendagitis epiploica primaria: Clínica y evolución de 73 casos

La apendagitis epiploica primaria es una enfermedad relativamente infrecuente dentro de los diagnósticos diferenciales del abdomen agudo. Describimos las características clínicas y evolución de una serie de 73 casos de apendagitis epiploica primaria. Se realizó una búsqueda de imágenes ecográficas y tomográficas con diagnóstico de apendagitis en el sistema de información hospitalario electrónico del Hospital Alemán entre abril del 2007 y julio del 2013 y posteriormente se revisaron sus historias clínicas. Se incluyeron 73 casos; la edad promedio fue de 45 años (± 16), 54 (74%) eran varones. El motivo de consulta fue dolor abdominal: en fosa ilíaca izquierda en 65 (el 89% de los casos); en fosa ilíaca derecha en seis (8%) y en otras localizaciones en dos (3%). Se les realizó ecografía abdominal a 44 (60%), tomografía computarizada a 21 (29%), y ambos estudios a 8 (11%). En el 49% de los casos se solicitó interconsulta con el servicio de cirugía. Recibieron tratamiento con antibióticos 15 (21%) pacientes, de los cuales el 73% fue indicado por un médico clínico. Recibieron tratamiento ambulatorio con antiinflamatorios no esteroides 67 (92%); dos requirieron cirugía laparoscópica, dos internación y dos opiáceos. La apendagitis epiploica es infrecuente dentro de los diagnósticos diferenciales de abdomen agudo, pero es una entidad que no debe ser desconocida por los médicos para prevenir intervenciones innecesarias y el uso excesivo de antibióticos.

Primary epiploic appendagitis is a relatively rare disease in the differential diagnosis of acute abdomen, nonetheless it is an entity that should not be ignored by physicians and surgeons in order to prevent unnecessary interventions and overuse of antibiotics. To substantiate this concept a search was conducted at the Hospital Aleman, Buenos Aires between April 2007 and July 2013. The aim was clinical histories containing sonographic and tomographic images with diagnosis of omental appendagitis; and subsequently their electronic medical records were reviewed. The clinical features and outcome of a case series of 73 primary omental appendagitis were selected; the mean age was 45 years (± 16); 54 (74%) were men. Abdominal pain (left lower quadrant in 89% of cases) was the most common symptom. Abdominal ultrasound was performed on 44 (60%) of patients, computed tomography on 21 (29%), and both studies on 8 (11%) of cases in this series. In 49% of cases surgery consultation was requested. Fifteen patients (21%) were treated with antibiotics, 73% of them were prescribed by a clinician. Sixty seven patients (92%) were treated as outpatients with non steroidal anti-inflammatory drugs (NSAIDs); two required laparoscopic surgery, two required hospitalization and two others were treated with opioids. Epiploic apendagitis is uncommon in the differential diagnosis of acute abdomen, but is an entity that should not be ignored by physicians to prevent unnecessary interventions and overuse of antibiotics.

Prokinetic drug utility in the treatment of gastroesophageal reflux esophagitis: a systematic review of randomized controlled trials.

BACKGROUND: Esophagitis caused by gastroesophageal reflux disease (GERD) results in appreciable morbidity and economic burden. No systematic review has addressed the effectiveness of prokinetic drugs in the treatment of GERD esophagitis in adults. OBJECTIVE: To determine the utility of prokinetic drugs in improving symptoms and endoscopic lesions in patients with GERD esophagitis. METHODS: We included randomized controlled trials that compared prokinetic drugs with placebo. A systematic search included the Cochrane Controlled Trial Register, MEDLINE, CINAHL, LILACS, EMBASE, a manual search of books and article references, and contact with pharmaceutical companies. Reviewers assessed methodological quality and extracted data that were combined using a random effects model. RESULTS: Eighteen articles met the eligibility criteria; of these, 13 used prokinetic drugs alone, 4 tested prokinetic drugs as additional therapy in patients receiving histamine-2 receptor blockers, and 1 tested them in patients receiving proton pump inhibitors. Seven studies evaluated clinical improvement only, 5 addressed endoscopic improvement only, and 6 reported both outcomes. Four studies failed to provide adequate data for pooling; 3 of the 4 reported results that suggested symptomatic benefit with prokinetic agents. Nine studies (379 patients) that provided the required data suggested a higher incidence of clinical improvement with prokinetic drugs versus placebo (relative risk [RR] 1.70, 95% confidence interval [CI] 1.37-2.12, heterogeneity p = 0.47, I(2) = 0%). Clinical improvement occurred in 53 out of 175 patients (30%) of the control group; applying the relative risk of 1.70 and associated confidence interval suggests that absolute increases in patients improved might vary from 18% to 41% (number needed to treat approximately 3 to 6). Improvement was similar in 4 studies in which the prokinetic agent was added to an antisecretory drug. The funnel plot, however, suggests the possibility of publication bias. Eleven studies (887 patients) suggested a higher likelihood of endoscopic improvement or healing esophagitis with prokinetic drugs (RR 1.26, 95% CI 1.03-1.53) but with significant heterogeneity (heterogeneity p = .05, I(2) = 46.2%) that we couldn't explain with an a priori hypothesis. When we evaluated endoscopic healing as the main outcome we observed a trend toward better results in the treatment group, also with inexplicable heterogeneity (RR 1.36, CI 95% 0.97-1.89, I(2) = 61%). CONCLUSIONS: Randomized controlled trials provide moderate-quality evidence that prokinetic drugs improve symptoms in patients with reflux esophagitis and low-quality evidence that they have an impact on endoscopic healing.

Tipos de diseño de investigación: ejemplos en el campo de la anestesiología / Types of research designs: examples in the field of anesthesiology

Los diseños de investigación deben entenderse como el camino que tomaremos para conseguir las respuestas a los interrogantes clínicos que nos planteamos. La selección del tipo de diseño va a depender de distintas variables, todas de suma importancia, como son el objetivo general del investigador, los recursos de los que dispone, la factibilidad y cuestiones éticas que se valoren. Cada tipo de diseño presenta ventajas y desventajas, conocerlas, nos ayudará a seleccionar el más adecuado.

¿Cuánto cuesta y quién paga la dependencia en las personas mayores?: un estudio en la Ciudad de Buenos Aires

Contenido: Servicios para la dependencia, costos y bienestar de las personas mayores en la experiencia internacional. Los servicios de larga duración, los costos y el bienestar en la Argentina. Costos de la dependencia y bienestar de las personas mayores en el estudio de la ciudad de Buenos Aires. Modelos de regresión logística. Escalas de valoración