Parental Burnout Assessment (PBA) in Different Hispanic Countries: An Exploratory Structural Equation Modeling Approach.

Parental burnout is a unique and context-specific syndrome resulting from a chronic imbalance of risks over resources in the parenting domain. The current research aims to evaluate the psychometric properties of the Spanish version of the Parental Burnout Assessment (PBA) across Spanish-speaking countries with two consecutive studies. In Study 1, we analyzed the data through a bifactor model within an Exploratory Structural Equation Modeling (ESEM) on the pooled sample of participants (N = 1,979) obtaining good fit indices. We then attained measurement invariance across both gender and countries in a set of nested models with gradually increasing parameter constraints. Latent means comparisons across countries showed that among the participants' countries, Chile had the highest parental burnout score, likewise, comparisons across gender evidenced that mothers displayed higher scores than fathers, as shown in previous studies. Reliability coefficients were high. In Study 2 (N = 1,171), we tested the relations between parental burnout and three specific consequences, i.e., escape and suicidal ideations, parental neglect, and parental violence toward one's children. The medium to large associations found provided support for the PBA's predictive validity. Overall, we concluded that the Spanish version of the PBA has good psychometric properties. The results support its relevance for the assessment of parental burnout among Spanish-speaking parents, offering new opportunities for cross-cultural research in the parenting domain.

Infecciones respiratorias superiores virales en una central de emergencias: estudio de cohorte retrospectiva / Upper respiratory tract infection on an Emergency Department: retrospective cohort

Estimar la frecuencia de cuadro de vías aéreas superiores (CVAS) como motivo de consulta no programada, describir el proceso de atención y explorar la variación tras la implementación de una nueva estrategia de gestión para la atención, así como el efecto en los indicadores de calidad y seguridad de atención. Cohorte retrospectiva que incluyó consultas por CVAS entre 01/01/2015 y 31/12/2016 de Demanda Espontánea (consultas de baja complejidad de la Central de Emergencia de Adultos), en el Hospital Italiano de Buenos Aires. La prevalencia global del período 2015-2016 resultó 12,01% (21.581/179.597). La intervención múltiple, resultó efectiva en términos de disminución de estudios complementarios (19% antes y 17% después con p=0,001), disminución de laboratorios (9% antes y 8% después con p=0,009), y reducción del tiempo de atención (media de 51 minutos antes y 42 minutos después, con p=0,001). No hubo diferencias significativas en la incidencia acumulada de reconsultas a los 7 días (12,72% antes y 13,11% después con p=0,400) ni en la tasa de internaciones a los 7 días (0,42% antes y 0,38% después con p=0,651) desde la consulta índice (primer consulta en guardia). En un sistema sobresaturado, se requiere fortalecer los sistemas de atención primaria que conforman la puerta de entrada de la salud para garantizar la correcta utilización de los recursos disponibles, la solicitud de estudios apropiados y la indicación correcta de antibióticos. Muchas lecciones aprendidas facilitaron la organización y la reestructuración necesarias durante la pandemia COVID-19 (AU)

To estimate upper respiratory tract infection (URTI) frequency as a reason for unscheduled consultation, to describe the care process and to explore the variation after the implementation of a new management strategy for care, as well as the effect on quality and security indicators of care. Retrospective cohort which included consecutive consultations by URTI between 01/01/2015 and 12/31/2016 for ambulatory clinic (low complexity consultations at the Emergency Department), at the Hospital Italiano de Buenos Aires. The prevalence for the period 2015-2016 was 12.01% (21,581/179,597). The multiple intervention was effective in terms of reduction of complementary studies (19% before and 17% after; p =0.001), reduction of laboratories (9% before and 8% after; p=0.009), and reduction of attention time (mean of 51 minutes before and 42 minutes after; p=0.001). During the follow up, there were no significant differences in the cumulative incidence of reconsultations at 7 days (12.72% before and 13.11% after; p=0.400) or in the rate of hospitalizations at 7 days (0.42% before and 0.38% after; p=0.651) from the index consultation. In an overcrowded system, it is necessary to strengthen the primary care systems that make up the gateway to health to guarantee the correct use of available resources, the request for appropriate studies and the correct indication of antibiotics. Many lessons learned facilitated the organization and restructuring of the Emergency Department needed during the COVID-19 pandemic (AU)

Los desafíos en la formación de los futuros médicos / Challenges in the training of future doctors

En este artículo, el autor reflexiona sobre sobre el presente y el futuro de la educación médica en el contexto de las tecnologías de la información y de la convivencia de nuestro trabajo con los dispositivos de inteligencia artificial, de los nuevos contenidos de genética y neurociencias, del trabajo en equipo y de la necesaria resignifificación de los términos "cura" y "cuidado". Se pregunta además si estamos en condiciones de encarar dicho desafío y de estar a la altura de las necesidades educativas de las próximas (y la actual) generación/es de médicos. (AU)

In this article, the author reflects on the present and the future of medical education in the context of information technologies and the coexistence of our work with artificial intelligence devices, the new contents of genetics and neurosciences, about team work and the necessary resignification of the terms "cure" and "care". He also wonders if we are able to face this challenge and to deal with the educational needs of the next (and the current) generation/s of doctors. (AU)

Colonoscopy overuse in colorectal cancer screening and associated factors in Argentina: a retrospective cohort study.

BACKGROUND: In recent years, there has been growing concern about the overuse of colonoscopy (CC). Our objective was to evaluate the incidence rate and cumulative probability of having a potentially inadequate CC (PI-CC, e.g. a CC that was performed earlier that recommended) and the association between the report of a hyperplastic polyp in the baseline CC report and the probability of having a PI-CC. METHODS: A retrospective cohort of adults 50y/o or older with a complete baseline CC between January 1st and December 31st 2005, without reported lesions or with hyperplastic polyps, based on secondary data extracted from the electronic medical record of the Hospital Italiano of Buenos Aires. The outcome consisted of time until a PI-CC, defined as the time measured between basal colonoscopy and a colonoscopy performed earlier than the inter-screening interval recommended by the USPSTF and the USMSTF. RESULTS: 389 patients were included. The cumulative probability of receiving a PI-CC over 10 years was 0.29 (95% CI 0.241, 0.342). The incidence rate resulted in 30.91 PI-CC per 1000 person-years (95% CI 25.14, 38). The crude analysis of the association between the outcome and the presence of hyperplastic polyps in the baseline CC, showed a statistically significant difference between both groups (log rank, p 0.036). The multivariate analysis yielded a hazard ratio of 1.67 (95% CI 1.02-2.73). CONCLUSION: We observed that 3 in every 10 patients treated in our health system received a PI-CC during the first ten consecutive years after a normal complete CC. Furthermore, this could be in part attributed to the presence of a hyperplastic polyp in the baseline CC.

Development and validation of various phenotyping algorithms for Diabetes Mellitus using data from electronic health records.

BACKGROUND AND OBJECTIVE: Recent progression towards precision medicine has encouraged the use of electronic health records (EHRs) as a source for large amounts of data, which is required for studying the effect of treatments or risk factors in more specific subpopulations. Phenotyping algorithms allow to automatically classify patients according to their particular electronic phenotype thus facilitating the setup of retrospective cohorts. Our objective is to compare the performance of different classification strategies (only using standardized problems, rule-based algorithms, statistical learning algorithms (six learners) and stacked generalization (five versions)), for the categorization of patients according to their diabetic status (diabetics, not diabetics and inconclusive; Diabetes of any type) using information extracted from EHRs. METHODS: Patient information was extracted from the EHR at Hospital Italiano de Buenos Aires, Buenos Aires, Argentina. For the derivation and validation datasets, two probabilistic samples of patients from different years (2005: n = 1663; 2015: n = 800) were extracted. The only inclusion criterion was age (≥40 & <80 years). Four researchers manually reviewed all records and classified patients according to their diabetic status (diabetic: diabetes registered as a health problem or fulfilling the ADA criteria; non-diabetic: not fulfilling the ADA criteria and having at least one fasting glycemia below 126 mg/dL; inconclusive: no data regarding their diabetic status or only one abnormal value). The best performing algorithms within each strategy were tested on the validation set. RESULTS: The standardized codes algorithm achieved a Kappa coefficient value of 0.59 (95% CI 0.49, 0.59) in the validation set. The Boolean logic algorithm reached 0.82 (95% CI 0.76, 0.88). A slightly higher value was achieved by the Feedforward Neural Network (0.9, 95% CI 0.85, 0.94). The best performing learner was the stacked generalization meta-learner that reached a Kappa coefficient value of 0.95 (95% CI 0.91, 0.98). CONCLUSIONS: The stacked generalization strategy and the feedforward neural network showed the best classification metrics in the validation set. The implementation of these algorithms enables the exploitation of the data of thousands of patients accurately.

A rule-based electronic phenotyping algorithm for detecting clinically relevant cardiovascular disease cases.

BACKGROUND: The implementation of electronic medical records (EMR) is becoming increasingly common. Error and data loss reduction, patient-care efficiency increase, decision-making assistance and facilitation of event surveillance, are some of the many processes that EMRs help improve. In addition, they show a lot of promise in terms of data collection to facilitate observational epidemiological studies and their use for this purpose has increased significantly over the recent years. Even though the quantity and availability of the data are clearly improved thanks to EMRs, still, the problem of the quality of the data remains. This is especially important when attempting to determine if an event has actually occurred or not. We sought to assess the sensitivity, specificity, and agreement level of a codes-based algorithm for the detection of clinically relevant cardiovascular (CaVD) and cerebrovascular (CeVD) disease cases, using data from EMRs. METHODS: Three family physicians from the research group selected clinically relevant CaVD and CeVD terms from the international classification of primary care, Second Edition (ICPC-2), the ICD 10 version 2015 and SNOMED-CT 2015 Edition. These terms included both signs, symptoms, diagnoses and procedures associated with CaVD and CeVD. Terms not related to symptoms, signs, diagnoses or procedures of CaVD or CeVD and also those describing incidental findings without clinical relevance were excluded. The algorithm yielded a positive result if the patient had at least one of the selected terms in their medical records, as long as it was not recorded as an error. Else, if no terms were found, the patient was classified as negative. This algorithm was applied to a randomly selected sample of the active patients within the hospital's HMO by 1/1/2005 that were 40-79 years old, had at least one year of seniority in the HMO and at least one clinical encounter. Thus, patients were classified into four groups: (1) Negative patients (2) Patients with CaVD but without CeVD; (3) Patients with CeVD but without disease CaVD; (4) Patients with both diseases. To facilitate the validation process, a stratified sample was taken so that each of the groups represented approximately 25% of the sample. Manual chart review was used as the gold standard for assessing the algorithm's performance. One-third of the patients were assigned randomly to each reviewer (Cohen's kappa 0.91). Both coded and un-coded (free text) sections of the EMR were reviewed. This was done from the first present clinical note in the patients chart to the last one registered prior to 1/1/2005. RESULTS: The performance of the algorithm was compared against manual chart review. It yielded high sensitivity (0.99, 95% CI 0.938-0.9971) and acceptable specificity (0.86, 95% CI 0.818-0.895) for detecting cases of CaVD and CeVD combined. A qualitative analysis of the false positives and false negatives was performed. CONCLUSIONS: We developed a simple algorithm, using only standardized and non-standardized coded terms within an EMR that can properly detect clinically relevant events and symptoms of CaVD and CeVD. We believe that combining it with an analysis of the free text using an NLP approach would yield even better results.

Development and Validation of Various Phenotyping Algorithms for Diabetes Mellitus Using Data from Electronic Health Records.

Precision medicine requires extremely large samples. Electronic health records (EHR) are thought to be a cost-effective source of data for that purpose. Phenotyping algorithms help reduce classification errors, making EHR a more reliable source of information for research. Four algorithm development strategies for classifying patients according to their diabetes status (diabetics; non-diabetics; inconclusive) were tested (one codes-only algorithm; one boolean algorithm, four statistical learning algorithms and six stacked generalization meta-learners). The best performing algorithms within each strategy were tested on the validation set. The stacked generalization algorithm yielded the highest Kappa coefficient value in the validation set (0.95 95% CI 0.91, 0.98). The implementation of these algorithms allows for the exploitation of data from thousands of patients accurately, greatly reducing the costs of constructing retrospective cohorts for research.

Antigenicity and immunogenicity of Plasmodium vivax merozoite surface protein-3.

A recent clinical trial in African children demonstrated the potential utility of merozoite surface protein (MSP)-3 as a vaccine against Plasmodium falciparum malaria. The present study evaluated the use of Plasmodium vivax MSP-3 (PvMSP-3) as a target antigen in vaccine formulations against malaria caused by P. vivax. Recombinant proteins representing MSP-3α and MSP-3ß of P. vivax were expressed as soluble histidine-tagged bacterial fusions. Antigenicity during natural infection was evaluated by detecting specific antibodies using sera from individuals living in endemic areas of Brazil. A large proportion of infected individuals presented IgG antibodies to PvMSP-3α (68.2%) and at least 1 recombinant protein representing PvMSP-3ß (79.1%). In spite of the large responder frequency, reactivity to both antigens was significantly lower than was observed for the immunodominant epitope present on the 19-kDa C-terminal region of PvMSP-1. Immunogenicity of the recombinant proteins was studied in mice in the absence or presence of different adjuvant formulations. PvMSP-3ß, but not PvMSP-3α, induced a TLR4-independent humoral immune response in the absence of any adjuvant formulation. The immunogenicity of the recombinant antigens were also tested in formulations containing different adjuvants (Alum, Salmonella enterica flagellin, CpG, Quil A,TiterMax® and incomplete Freunds adjuvant) and combinations of two adjuvants (Alum plus flagellin, and CpG plus flagellin). Recombinant PvMSP-3α and PvMSP-3ß elicited higher antibody titers capable of recognizing P. vivax-infected erythrocytes harvested from malaria patients. Our results confirm that P. vivax MSP-3 antigens are immunogenic during natural infection, and the corresponding recombinant proteins may be useful in elucidating their vaccine potential.

Comparative recognition by human IgG antibodies of recombinant proteins representing three asexual erythrocytic stage vaccine candidates of Plasmodium vivax.

In previous immuno-epidemiological studies of the naturally acquired antibody responses to merozoite surface protein-1 (MSP-1) of Plasmodium vivax, we had evidence that the responses to distinct erythrocytic stage antigens could be differentially regulated. The present study was designed to compare the antibody response to three asexual erythrocytic stage antigens vaccine candidates of P. vivax. Recombinant proteins representing the 19 kDa C-terminal region of MSP-1(PvMSP19), apical membrane antigen n-1 ectodomain (PvAMA-1), and the region II of duffy binding protein (PvDBP-RII) were compared in their ability to bind to IgG antibodies of serum samples collected from 220 individuals from the state of Pará, in the North of Brazil. During patent infection with P. vivax, the frequency of individuals with IgG antibodies to PvMSP1(19), PvAMA-1, and PvDBP-RII were 95, 72.7, and 44.5% respectively. Although the frequency of responders to PvDBP-RII was lower, this frequency increased in individuals following multiple malarial infections. Individually, the specific antibody levels did not decline significantly nine months after treatment, except to PvMSP1(19). Our results further confirm a complex regulation of the immune response to distinct blood stage antigens. The reason for that is presently unknown but it may contribute to the high risk of re-infection in individuals living in the endemic areas.

Comparative recognition by human IgG antibodies of recombinant proteins representing three asexual erythrocytic stage vaccine candidates of Plasmodium vivax

In previous immuno-epidemiological studies of the naturally acquired antibody responses to merozoite surface protein-1 (MSP-1) of Plasmodium vivax, we had evidence that the responses to distinct erythrocytic stage antigens could be differentially regulated. The present study was designed to compare the antibody response to three asexual erythrocytic stage antigens vaccine candidates of P. vivax. Recombinant proteins representing the 19 kDa C-terminal region of MSP-1(PvMSP19), apical membrane antigen n-1 ectodomain (PvAMA-1), and the region II of duffy binding protein (PvDBP-RII) were compared in their ability to bind to IgG antibodies of serum samples collected from 220 individuals from the state of Pará, in the North of Brazil. During patent infection with P. vivax, the frequency of individuals with IgG antibodies to PvMSP1(19), PvAMA-1, and PvDBP-RII were 95, 72.7, and 44.5 percent respectively. Although the frequency of responders to PvDBP-RII was lower, this frequency increased in individuals following multiple malarial infections. Individually, the specific antibody levels did not decline significantly nine months after treatment, except to PvMSP1(19). Our results further confirm a complex regulation of the immune response to distinct blood stage antigens. The reason for that is presently unknown but it may contribute to the high risk of re-infection in individuals living in the endemic areas.