Prevalence of the use of antidepressants in patients with venous thromboembolism / Prevalencia del uso de antidepresivos en pacientes con enfermedad tromboembólica venosa.

OBJECTIVE: To estimate the prevalence of Antidepressant use in patients with a history of venous thromboembolism (VTE). Describe the patient's characteristics and which drugs are the most prescribed. METHODS: A cross-sectional study involving a consecutive sample of patients included in the Registro de Enfermedad Tromboembólica (RIET) from the Hospital Italiano de Buenos Aires in a period between 01/01/2014 to 01/09/2018. All patients presented symptomatic VTE and confirmed diagnosis. Drugs considered included in this study were: Selective Serotonin Reuptake Inhibitors (SSRI), Dopamine and Norepinephrine Reuptake Inhibitors (NDRI), Serotonin and Norepinephrine Reuptake Inhibitors (SNRI) and Tricyclic antidepressants (TCA). RESULTS: From a total of 2373 patients with VTE, 472 were active users of antidepressants, showing a prevalence of antidepressant use of 19.9% (CI 95%). The most frequently prescribed drugs by drug classification were: SSRI 83.9%, TCA 20.5%, ISRN 14.6%, and NDRI 2.5%. Patients presented a median age of 76 years, predominantly women (71.4%), with several comorbidities: 52.24% arterial hypertension, 37.29% overweight, and 34.75% history of smoking. Concerning relevant history, we observed: 29.03% active oncologic disease, 26.27% major surgery before the VTE, and 21.61% previous VTE. CONCLUSION: The prevalence of antidepressant use in patients with VTE is 19.9%, superior by far to that of the general population. Depression is a major cause of morbidity worldwide, and its prevalence is increasing over the years.

OBJETIVOS: Estimar la prevalencia de consumo de fármacos antidepresivos en pacientes que hayan sufrido un evento tromboembólico venoso (TEV), describir esta población y las drogas más utilizadas. MATERIAL Y MÉTODOS: Corte transversal que incluyó una muestra consecutiva de adultos incluidos en el Registro de Enfermedad Tromboembólica (RIET) del Hospital Italiano de Buenos Aires entre el 01/01/2014 y el 1/09/2018. Se consideraron los siguientes fármacos: Inhibidores Selectivos de la Recaptación de Serotonina (IRSS), Inhibidores de la Recaptación de Dopamina y Noradrenalina (IRDN), Inhibidores de la Recaptación de Serotonina y Noradrenalina (IRSN), y Antidepresivos Tricíclicos (ATC). RESULTADOS: De un total de 2373 pacientes, 472 se identificaron como usuarios activos de antidepresivos, arrojando una prevalencia de 19,9% (IC95% de 18,3-21,6). Según familia farmacológica, en orden de mayor a menor frecuencia, se indicaron: IRSS 83,9%, ATC 20,5%, IRS 14,6% e IRDN y IRDN 2,5%. Los pacientes bajo tratamiento con antidepresivos presentaron una mediana de edad de 76 años, mayoritariamente mujeres (71,4%), con alta carga de comorbilidad: 52,24% hipertensión arterial, 37,29% sobrepeso, 34,75% ex tabaquismo. Los antecedentes de mayor frecuencia resultaron enfermedad oncológica activa (29,03%), cirugía mayor en último mes (26,27%), y el 21,61% presentaba ETV previa. CONCLUSIONES: La prevalencia de uso de antidepresivos en pacientes con ETV resultó 19,9%, superior a la población general. La depresión es una causa principal de enfermedad y discapacidad en todo el mundo, cuya prevalencia aumentó durante los últimos años.

Hospitalization for venous thromboembolic disease management: a 10 years Registry in Buenos Aires, Argentina.

Venous thromboembolism (VTE) is the most frequent cause of preventable mortality in hospitalized patients and the third leading cause of mortality due to vascular diseases. We aim to describe patients with VTE who required hospitalization, their clinical characteristics, management and evolution after discharge. Prospective cohort which included patients with acute and symptomatic VTE who required hospitalization in a single tertiary center for their management in a 10 years´ period (between 2006 and 2016). Patients were included at the time of VTE diagnosis; we collected baseline characteristics, risk stratification and initial therapeutic approach. They were periodically, prospectively and systematically followed up to evaluate recurrence, bleeding and/or death. Time-to-event analysis was performed for these outcomes related to evolucion after discharge. 3457 confirmed VTE episodes were included for the analysis (1985 DVT, 930 PE and 542 DVT + DVT), corresponding to 3157 patients. Most were elderly, the median age was 68 years (SD 16) with a predominance of women 57% (1955). Most frequent predisposing factors were immobility (45%), active cancer (35%), recent surgery (33%), obesity (26%), recent hospitalization (22%) and previous VTE (21%). One-fourth of pulmonary embolism had sPESI 0 points. Mortality, recurrence and bleeding rates within 30 days were 14%, 10% and 5% respectively. High proportion of VTE require hospitalization for their management, even PE with low sPESI. Mortality and complication remain elevated. We encourage the development and maintenance of more VTE registries in Latin America, to fully understand local characteristics of this disease.

[Undertriage as quality of care parameter in an emergency department]. / Medición del subtriaje como indicador de calidad y seguridad en un servicio de urgencias.

BACKGROUND: Undertriage or the underestimation of the urgency of the condition of a person arriving in an emergency department (ED) represents a measure of quality care. AIM: To estimate the prevalence of undertriage in a high complexity hospital of Argentina; to describe characteristics and mortality of these patients. MATERIAL AND METHODS: All consultations admitted to the ED during 2014 were analyzed. Those assigned to a lower level of admission risk (classified as Emergency Severity Index -ESI- 3 to 5) but required hospitalization in intensive care units (ICU) as the first hospitalization place were considered as an undertriage. A random sample of correctly categorized admissions (ESI 1 or 2), who were subsequently hospitalized in the ICU, was selected as a comparison group. RESULTS: The global undertriage prevalence was 0.30% (316/104,832). Among patients admitted to the ICU, the prevalence was 21% (316/1,461; 95% confidence intervals (CI) 19-24). The 316 patients whose severity was underestimated had a median age of 73 years, and admitted between 7 a.m. and 9 p.m. in a greater proportion. Overall hospital mortality was 8.9% (95% CI 6.78-11.38), and all deaths occurred after the patient was transferred from the emergency room. There were no differences in mortality between patients with correct triage or undertriage (11 and 7% respectively, p = 0.09). No differences were observed either in the total number of critical interventions during care in the first 24 hours. Significant differences were observed in requirements for mechanical ventilation (11 and 4% respectively, p = 0.01), orotracheal intubation (10 and 5% respectively p = 0.01) and non-invasive ventilation (8 and 4% respectively, p = 0.05). CONCLUSIONS: Undertriage rate in this series was low, but it can be improved.

[Analysis of Crowding in an Adult Emergency Department of a tertiary university hospital]. / Descripción de las características del fenómeno Crowding en la Central de Emergencia de Adultos, en un hospital universitario de alta complejidad: estudio de cohorte retrospectiva.

BACKGROUND: Crowding in Emergency Departments (ED), results from the imbalance between the simultaneous demand for health care and the ability of the system to respond. The NEDOCS scale (National Emergency Department Crowding Scale) measures the degree of crowding in an ED. AIM: To describe ED Crowding characteristics, using the NEDOCS scale, in an Argentinean hospital. MATERIAL AND METHODS: A retrospective cohort study was conducted with all adult patient consultations between July 2013 and July 2014 at the ED of Hospital Italiano de Buenos Aires. We included all hours in the analysis period (365 days x 24 h = 8,760). The NEDOCS value was calculated for each hour using an automatic algorithm and was quantified in a six points score. Levels 4 (overcrowded), 5 (severely overcrowded) and 6 (dangerously overcrowded) were defined as overcrowding. Contour plots analysis was applied to identify patterns. RESULTS: During the study period, 124,758 visits to the ED were registered. Overcrowding was present in 57.7% (5,055) of the analyzed hours. A predominance of scores between four and five was observed between 10:00 and 24:00 hours. The months with predominance of overcrowding were June, July and August (southern winter). CONCLUSIONS: The calculation of the NEDOCS score and the analysis of its temporal distribution are highly relevant to identify opportunities for improvement and to develop mechanisms to prevent the highest categories of overcrowding.

Inhospital mortality among clinical and surgical inpatients recently diagnosed with venous thromboembolic disease.

Venous thromboembolism (VTE) is the most common cause of preventable mortality in hospitalized patients, and pulmonary embolism is responsible for 5-10 % of all hospital deaths. To estimate the hospital mortality in hospitalized patients who developed VTE during hospitalization. Prospective cohort of all adult inpatients >17 years admitted to the hospital between August 2006 and August 2013, and follow-up until discharge to measure death. VTE incident cases were captured prospectively from the Institutional Registry of Thromboembolic disease in a tertiary hospital care in Buenos Aires. In hospital global mortality and fatality rate of inpatients with VTE was calculated. The cumulative incidence of VTE was 1.8 % (95 % CI 1.77-1.93 %), representing 1.32 % (95 % CI 1.23-1.41 %) in the subgroup of surgical patients and 2.1 % (95 % CI 1.9-2.2 %) in clinical inpatients. The overall hospital mortality was 2.4 % (95 % CI 2.35-2.53); being 3.95 % (95 % CI 3.78-4.12) in clinical inpatients and 1.15 % (95 % CI 1.06-1.23) in surgical patients. The death in patients who had developed VTE, represented between 4 and 7 % of hospital deaths, and it increases with age in both clinical and surgical patients. In Argentina there are few data of hospital mortality in patients with VTE. This information is useful when assessing the need for resources for prevention, diagnosis and treatment in inpatients.

Problem Detection and Optimization of a Personal Health Record Driven by a Helpdesk Support Tool.

This study aims to assess the value of a help desk in a Personal Health Record (PHR) for monitoring and improving PHR functionalities and processes. Through analysis of 327 help desk tickets categorized by users as telemedicine and PHR requests, we identified four main gaps: information and feedback, access to clinical documents, usability, and ubiquity. The tickets highlighted end users' needs such as timely feedback, contextual information, effective communication, and ease of access to clinical documentation. These findings were crucial for initiating improvement cycles for various functionalities and processes within the PHR.

[Critical patients in general hospitalization wards: a descriptive analysis of factors inherent to the transfer to a closed unit] / El paciente crítico en sala de internación general.

Introduction: Unplanned transfers from the General Ward to Critical Care Units occur due to a deterioration in the patient's clinical status. They are of great interest because of their negative impact, associated with longer hospital stays and higher mortality. Objectives: To report the frequency at which these transfers occur, characteristics of these patients and causes of the transfer. Identify shortcomings in the care process that may allow improvement strategies. Methodology: cross-sectional study. Cases were considered those who, during the first 24 hours of hospitalization in the General Ward, required transfer to the ICU between January - December 2022 in a high-complexity hospital in Buenos Aires. Results: Of 8317 admissions, 124 were transferred to the ICU, with a rate of 14 per 1000 and an average of 70 years. The most frequent comorbidities were high blood pressure, heart failure, cancer and overweight-obesity. The main causes of hospitalization were respiratory and gastrointestinal symptoms. 67% had non-alarming results in the NEWS score prior to transfer to the ICU. The most frequent causes were respiratory failure, hemodynamic instability and requirement for monitoring. Average hospital stay was 10 days and in-hospital mortality was 26%. Conclusions: Respiratory decompensation in elderly male patients was the most common cause of transfer to a Closed Unit. One of the shortcomings of the care process seems to be the NEWS score, where in 67% of cases it did not warn about the high requirement of patient monitoring.

Introducción: Los traslados no programados, de Sala General a Unidades de Cuidados Críticos, se producen debido a un deterioro en el estado clínico del paciente. Son de gran interés debido a su impacto negativo, asociado con estadías hospitalarias más largas y mayor mortalidad. Objetivos: Reportar la frecuencia en la que ocurren estos traslados, las características de estos pacientes y las causas del pase. Identificar falencias del proceso asistencial que permitan generar estrategias de mejora. Metodología: estudio de corte transversal. Se consideraron casos quienes durante las primeras 24 horas de internación en Sala General requirieron traslado a UCI entre Enero - Diciembre 2022 en un hospital de alta complejidad en Buenos Aires. Resultados: De 8317 ingresos 124 fueron trasladados a UCI, con una tasa de 14 por 1000 y una media de 70 años. Las comorbilidades más frecuentes fueron hipertensión arterial, insuficiencia cardíaca, cáncer y sobrepeso-obesidad. Las principales causas de internación fueron cuadros respiratorios y gastrointestinales. Un 67% tuvieron resultados no alarmantes en el score NEWS previo al pase a UCI. Las causas más frecuentes fueron insuficiencia respiratoria, inestabilidad hemodinámica y requerimiento de monitoreo. La estadía hospitalaria media fue de 10 días y la mortalidad intrahospitalaria 26%. Conclusión: Los descompensación respiratoria en pacientes añosos de sexo masculino fue la causa más común de pase a Unidad Cerrada.Una de las falencias del proceso asistencial pareciera ser el score NEWS, donde en un 67% de los casos no alertó sobre el alto requerimiento de monitoreo del paciente.

[Scope and limitations of teleconsultation during the covid-19 pandemic: accounts from primary healthcare professionals in the Autonomous City of Buenos Aires]. / Alcances y limitaciones de la teleconsulta en pandemia de covid-19: relatos de profesionales de la salud del primer nivel de atención de la Ciudad Autónoma de Buenos Aires.

The aim was to explore the scope and limitations of teleconsultation during the pandemic from the perspective of primary care physicians at the Hospital Italiano de Buenos Aires, a private institution located in the Autonomous City of Buenos Aires. A qualitative study was conducted with ten individual semi-structured interviews between January and April 2022. The three major emerging topics were the transition to virtuality, accessibility, and the new care model. Obstacles were related to the massive, forced, and unplanned implementation of teleconsultations. The main benefits included providing care during isolation-distancing and addressing epidemiological doubts. Changes were highlighted in care strategies, consultation frameworks, exchange among colleagues, referral criteria, requests for complementary studies, and in the profiles of those seeking consultations. A misuse of the system by individuals and a trivialization of the consultation moment emerged. The rise of communication and information technologies undoubtedly allowed the continuity of healthcare processes, but it does not replace in-person care, and normative guidelines are needed for its continuity.

El objetivo fue explorar alcances y limitaciones de la teleconsulta en pandemia, desde la perspectiva de médicos y médicas del primer nivel de atención del Hospital Italiano de Buenos Aires, una institución privada ubicada en la Ciudad Autónoma de Buenos Aires. Se realizó un estudio cualitativo con diez entrevistas semiestructuradas individuales entre enero y abril de 2022. Los tres grandes tópicos emergentes fueron la transición a la virtualidad, la accesibilidad y el nuevo modelo de atención. Los obstáculos se relacionaron con la implementación masiva, forzada y no planificada de las teleconsultas. Los principales beneficios fueron brindar atención durante el aislamiento-distanciamiento y evacuar dudas epidemiológicas. Se destacan cambios en estrategias de atención, encuadre de las consultas, intercambio entre colegas, criterios de derivación y de pedido de estudios complementarios, y en los perfiles de consultantes. Surgió un sobreuso del sistema por parte de las personas, y una banalización del momento de la consulta. El auge de las tecnologías de la comunicación e información indudablemente permitió dar continuidad a los procesos asistenciales en salud, pero no reemplaza la presencialidad y se requieren lineamientos normativos para su continuidad.

Effect of the COVID-19 Lockdown on Patients Valuation of Usability of Telemedicine.

The aim of this paper was to report patient valuation of usability with our telemedicine system and to explore the effect of pandemic in its behavior. We conducted a cross-sectional study based on the prospective recollection of the results of the Spanish abbreviated version of the Telehealth Usability Questionnaire (TUQ), from October 2019 to July 2020. We observed an inflection point of growth of answers during the pandemic era and a trend of decrease in usability valuations coinciding with the massive and forced implementation of the system after lockdown. This effect was transitory, evidencing an improvement over time. These results might be explained with a sociotechnical approach that includes considering the learning curve and suggest the importance of a telemedicine usability tool to guide decision-making. In conclusion, tools to assess telemedicine services may identify facilitators and barriers to its use in a highly changing social and technological context.

Comparison of clinical outcomes of venous thromboembolic disease between outpatient and inpatient management.

Objectives: To compare the occurrence of death, bleeding, and recurrence according to inpatient or outpatient management of venous thromboembolic disease (VTE). Materials and methods: . Retrospective cohort that included a consecutive sampling of VTE consultations between 2016 and 2019 diagnosed in the Emergency Center of a private hospital in Argentina. Results: There were 1202 cases, 908 with isolated deep vein thrombosis (DVT), 205 with isolated pulmonary embolism (PE), and 89 cases of combined DVT - PE. 66% were women, with a median age of 77 years; 72% of cases were managed on an outpatient basis (n= 862). Comorbidities associated with hospitalization were obesity (p=0.03), chronic obstructive pulmonary disease (COPD) (p=0.01), heart failure (CHF) (p=0.01), chronic renal failure (CKD) (p=0.01), and cancer (p=0.01). At 90 days, the cumulative incidence of bleeding was 2.6% in inpatient compared to 2.9% in outpatient management (p=0.81); recurrence was 0% versus 0.9% (p=0.07), and mortality was 42.9% versus 18.9%, respectively (p=0.01). The HR for 90-day mortality in hospitalized patients adjusted for confounders (sex, age, type of VTE, obesity, CKD, CHF, COPD, and cancer) was 1.99 (95% CI 1.49-2.64; p=0.01). Conclusions: In this elderly, and predominantly female Argentine population, the 90-day mortality in patients hospitalized for VTE was higher than mortality in patients with outpatient management, without differences in recurrence or major bleeding.

Age, Gender, Body Mass Index, and Foot Loading During Gait.

Background: The aim was to analyze changes in normal functional parameters of gait analysis by aging, sex, and body mass index (BMI). Methods: A cross-sectional study with a consecutive sample of asymptomatic subjects was performed between 2014 and 2020. Primary outcomes were time and force parameters (contact time and center of force [CoF] time), in the heel, midfoot, and metatarsal areas, measured using an in-office force platform. Results: A total of 156 subjects (312 feet) were included, including 67% of women with a mean age of 47 years. The mean of total contact time was similar in males and females (P = .695) and across BMI (P = .413). Contact time did not show differences by region (P = .648 heel, P = .286 midfoot, and P = .690 metatarsal). CoF time in the heel and metatarsal areas did not change between males and females (P = .288 and P = .879, respectively); meanwhile, it was different in midfoot (P = .002). Maximum force showed a reduction between sexes in the heel (P = .039) but did not in the midfoot and metatarsal areas. By age, differences were detected in the heel and metatarsal areas in females (P = .002 and P = .001) and the metatarsal area in males (P = .001). According to the age groups, total contact time increased in females (P = .001) but not in males (P = .018), and no differences were detected between foot areas. In females, CoF time did not change either foot areas or age groups. In males, CoF time values increased in the midfoot area in the older group (P = .001). Conclusion: Time variables did not change by foot region, independent of age, sex, and BMI. Heel maximum force decreased in females, probably linked to adaptive phenomena by aging. The midfoot remains stable, and acts as an undamaged "bridge." These parameters could be interpreted as normal in asymptomatic subjects. Level of Evidence: Level III, diagnostic and prognostic.

Efecto de la inactivación de las órdenes múltiples para solicitud de estudios complementarios en una central de emergencias.

Introducción. La plantilla de órdenes múltiples es una herramienta informática que podría producir consecuencias inadvertidas pese a sus innumerables beneficios. Nos propusimos explorar el efecto de su inactivación sobre las solicitudes de estudios complementarios y los costos asociados. Métodos. Corte transversal en la Central de Emergencias de Adultos del Hospital Italiano de Buenos Aires, que incluyó muestra consecutiva de consultas pre-intervención (Enero-Febrero 2020) y post-intervención (2021). Mediante el uso de bases secundarias, las variables incluidas fueron los débitos administrativos y sus respectivos precios de facturación. Resultados. Hubo 27.671 consultas en 2020 con una mediana de valor total de 474$, y 20.819 con 1.639$ en 2021. Tras el análisis restringido al área de consultorios de moderada complejidad (excluyendo consultas por COVID-19), se encontró: una disminución en la mediana del número de prácticas por consulta (mediana de 11 vs 10, p=0,001), una disminución en la solicitud de al menos una práctica de laboratorio (45% versus 39%, p=0,001), sin encontrar cambios significativos en costos globales (mediana 1.419$ vs 1.081$; p=0,122) ni en costos específicos de laboratorio (mediana 1.071$ vs 1.089$, p=0,710). Conclusión. Pese a la inflación interanual, se logró una reducción significativa en el número de prácticas y se mantuvieron los costos globales por consulta. Estos hallazgos demuestran la efectividad de la intervención, pero serán necesarias medidas educativas que apunten al recordatorio de los potenciales daños en la sobreutilización, y los costos sanitarios de los estudios innecesarios.

[Chemotherapy at the end of life is compatible with dignified death and palliative care] / Quimioterapia al final de la vida es compatible con muerte digna y cuidados paliativos.

Introduction: Cancer treatment is increasingly aggressive. The aim was to estimate who died due to cancer, to report use of chemotherapy (CT) in the last 3 months of life, and to describe clinical-epidemiological characteristics of these patients. Methods: We included a consecutive sample of deceased during 2017, affiliated to Hospital Italiano de Buenos Aires. Through manual review of medical helath records, they were classified according to the cause of death (cancer or other cause), validating diagnosis and baseline stage, performance status (PS). Prevalences with 95% CI are reported and descriptive statistics were used. Results: A total of 2293 adults died, 59% women with a median age of 84 years old. There were a total of 736 deaths from cancer, representing 32% (95%CI 30-34). This last subgroup were 54% women, with a median age of 75 years, and only one patient had advance directives. Regarding the place of death, 80% were hospitalized (65% general ward and 15% intensive care units). The most frequent tumors were: lung, colorectal-gastric, hematological, and breast. A total of 390 patients received CT at the end of life (53%; 95%CI 49-57), 53% being women and with a mean age of 68 years. Regarding the underlying oncological disease: 81% had a solid tumor, 75% advanced stage, and mostly with poor/regular ability to perform daily activities (25% PS3 and 32% PS4, respectively). Conclusion: There is a high frequency of CT at the end of life and deaths continue to be mainly in-hospital.

Introducción: El tratamiento oncológico es cada vez más agresivo. El objetivo de este trabajo fue estimar las personas fallecidas por causa oncológica, reportar la frecuencia de uso de quimioterapia (QT) en los últimos 3 meses de vida, y describir las características clínicas-epidemiológicas de estos pacientes. Métodos: Se incluyó una muestra consecutiva de fallecidos durante el 2017, afiliados a prepaga del Hospital Italiano de Buenos Aires. Mediante revisión de historias clínicas, se los clasificó según la causa de muerte (oncológico u otra causa), validando diagnóstico y estadio de base, performance status (PS). Se reportan prevalencias con IC95% y se utilizó estadística descriptiva. Resultados: Fallecieron 2293 personas, 59% mujeres con mediana de 84 años. Hubo un total de 736 fallecidos por cáncer, representando el 32% (IC95% 30-34). Este último subgrupo presentó una mediana de 75 años, 54% eran mujeres y sólo una paciente tenía directivas anticipadas. En cuanto al lugar de fallecimiento, 80% ocurrió hospitalizado (65% sala general y 15% unidad cerrada). Los tumores más frecuentes fueron: pulmón, colorrectal-gástrico, hematológico, y mama. Un total de 390 pacientes recibieron QT al final de la vida (53%; IC95% 49-57), siendo 53% mujeres y con promedio de 68 años. En cuanto a la enfermedad oncológica de base: 81% tenían tumor sólido, 75% estadío avanzado, y mayoritariamente con mala/regular capacidad para realizar actividades cotidianas (25% PS3 y 32% PS4 respectivamente). Conclusión: Existe una frecuencia preocupante del uso de QT en el fin de vida y los fallecimientos siguen siendo principalmente intrahospitalarios.

[Prognostic value of hospital hypoglycemia]. / Valor pronóstico de la hipoglucemia hospitalaria.

BACKGROUND: Hospital hypoglycemia (HH) is an important problem since it is linked to hospital death, prolonged stay and higher costs, both in people with and without diabetes, in the critical area and general ward, especially in cases of severe hypoglycemia. The objective of our work was to compare hospital mortality, transfer to the critical area and hospitalization periods in adults with HH according to its severity. METHODS: We conducted a retrospective cohort of adults hospitalized with hypoglycemia at the Hospital Italiano de Buenos Aires between 2013 and 2018. Three groups of hypoglycemia were defined: mild (glycemia between 70 and 54 mg/dl), severe (glycemia < 54 mg/dl and = 40 mg/dl) and critical (glycemia < 40mg/dl). RESULTS: A total of 5994 patients had HH, the majority presented mild hypoglycemia (72%). Severe and critical hypoglycemia, compared with mild hypoglycemia, were associated with higher mortality: OR 2.6 (95%CI 2.2-3.1) and 4.2 (95%CI 3.5-5.0) respectively; and increased hospitalization in critical care areas: OR 1.6 (95%CI 1.4-1.9) and 3.2 (95%CI 2.6-4.0) respectively. There were no differences in length of stay. DISCUSSION: This information provides, in our country, evidence on the prognostic value of hypoglycemia, whose greater severity is associated with increased hospitalization in critical areas and higher hospital mortality.

Introducción: La hipoglucemia hospitalaria (HH) es un problema importante ya que se vincula a muerte hospitalaria, estadía prolongada y mayores costos, en personas con y sin diabetes, en área crítica y sala general, sobre todo en los casos de hipoglucemia grave. El objetivo de nuestro trabajo fue comparar la mortalidad hospitalaria, pase a área crítica y tiempo de internación en adultos con HH, según la gravedad de la misma. Métodos: Se realizó un estudio de cohorte retrospectiva en pacientes adultos internados con hipoglucemia en el Hospital Italiano de Buenos Aires entre 2013 y 2018. Se definieron tres grupos de hipoglucemia: leve (glucemia entre 70 y 54 mg/dl), grave (glucemia < 54 mg/dl = 40 mg/dl) y crítica (glucemia < 40mg/dl). Resultados: Un total de 5994 pacientes tuvieron HH, la mayoría presentó hipoglucemia leve (72%). La hipoglucemia grave y la crítica, comparadas con la hipoglucemia leve se asociaron a una mayor mortalidad: OR 2.6 (IC95% 2.2-3.1) y 4.2 (IC95% 3.5-5.0) respectivamente; y a mayor internación en áreas de cuidados críticos: OR 1.6 (IC95% 1.4-1.9) y 3.2 (IC95% 2.6-4.0) respectivamente. No hubo diferencias en el tiempo de internación. Discusión: Esta información aporta evidencia en nuestro país, sobre el valor pronóstico de la hipoglucemia, cuya mayor gravedad se asocia a mayor internación en áreas críticas y mayor mortalidad hospitalaria.

Effect of computerized physician order entry inactivation to order complementary studies in an emergency department / [Efecto de la inactivación de las órdenes múltiples para solicitud de estudios complementarios en una central de emergencias.]

Introduction: The computerized provider order entry (CPOE) is a computing tool that could lead to unintended consequences despite its myriad benefits. We aimed to explore the effect of its inactivation on requests for complementary studies and the associated costs. Methods: Cross sectional study at the Emergency Department of Hospital Italiano de Buenos Aires, which included a consecutive sample of pre-intervention (January-February 2020) and post-intervention (2021) consultations. Using secondary bases, the variables included were administrative debits and their respective billing prices. Results: There were 27,671 consultations in 2020 with a total median value of $474, and 20,819 with $1,639 in 2021. After the analysis restricted to the area of ​​moderately complex clinics (excluding COVID-19 consultations), the following was found: a decrease in the median number of practices per consultation (median of 11 vs. 10, p=0.001), a decrease in the request for at least one laboratory practice (45% vs. 39%, p=0.001), without finding significant changes in global costs (median $1,419 vs. $1,081; p=0.122) or in specific laboratory costs (median $1,071 vs. $1,089, p=0.710). Conclusion: Despite inflation, a significant reduction in the number of practices was achieved and overall costs per consultation were maintained. These findings demonstrate the effectiveness of the intervention, but an educational intervention aimed at reminding the potential harm of overuse and the health costs of unnecessary studies will be necessary.

Introducción: La plantilla de órdenes múltiples es una herramienta informática que podría producir consecuencias inadvertidas pese a sus innumerables beneficios. Nos propusimos explorar el efecto de su inactivación sobre las solicitudes de estudios complementarios y los costos asociados. Métodos: Corte transversal en la Central de Emergencias de Adultos del Hospital Italiano de Buenos Aires, que incluyó muestra consecutiva de consultas pre-intervención (Enero-Febrero 2020) y post-intervención (2021). Mediante el uso de bases secundarias, las variables incluidas fueron los débitos administrativos y sus respectivos precios de facturación. Resultados: Hubo 27.671 consultas en 2020 con una mediana de valor total de 474$, y 20.819 con 1.639$ en 2021. Tras el análisis restringido al área de consultorios de moderada complejidad (excluyendo consultas por COVID-19), se encontró: una disminución en la mediana del número de prácticas por consulta (mediana de 11 vs 10, p=0,001), una disminución en la solicitud de al menos una práctica de laboratorio (45% versus 39%, p=0,001), sin encontrar cambios significativos en costos globales (mediana 1.419$ vs 1.081$; p=0,122) ni en costos específicos de laboratorio (mediana 1.071$ vs 1.089$, p=0,710). Conclusión: Pese a la inflación interanual, se logró una reducción significativa en el número de prácticas y se mantuvieron los costos globales por consulta. Estos hallazgos demuestran la efectividad de la intervención, pero serán necesarias medidas educativas que apunten al recordatorio de los potenciales daños en la sobreutilización, y los costos sanitarios de los estudios innecesarios.

[Clinical characteristics and care times in a chest pain unit of the emergency department of an argentine center]. / Características clínicas y tiempos de atención en una unidad de dolor torácico del servicio de emergencias de un centro argentino.

Objectives: . To report the frequency of precordial pain, describe clinical characteristics, and care times. Methods: . Retrospective descriptive study that included consultations in the Chest Pain Unit in 2021 in the emergency department of a private hospital in Argentina. Results: There were 1469 admissions for chest pain, yielding a frequency of 1.09% (95%CI 1.04-1.15). They were 52% men, mean age 62 years (SD ±15); 48% had hypertension and 32% dyslipidemia. The median time to initial ECG was 4.3 min (ICR 2.5-7.5); and 26 min (ICR 14-46) to medical evaluation. A total of 206 (14%) were hospitalized with a median of 3 days, 76% were admitted to a closed unit, 9% required non-invasive ventilation/mechanical ventilaction and in-hospital mortality was 2.9%. Those hospitalized presented shorter delay time to medical attention (p<0.01), and greater performance of complementary studies (p<0.01), with no differences in time to ECG (p=0.22). Conclusions: Care times were within the stipulated standards, being an important indicator of quality. Nursing was crucial, taking care of the correct triage, ECG on admission, and guaranteeing care until medical evaluation.

[Real-world evidence on pharmacological appropriateness in type 2 diabetes mellitus and cardiovascular disease]. / Evidencia de mundo real sobre adecuación farmacológica en diabetes tipo 2 y enfermedad cardiovascular.

Objective: To estimate the proportion of individuals with established Type 2 Diabetes Mellitus (T2DM) and Cardiovascular Disease (CVD) who are receiving pharmacological anti-diabetic treatment with evidence of cardiovascular benefit at a hospital in Argentina. Materials and Methods: Cross-sectional study conducted at the Italian Hospital of Buenos Aires. A consecutive sample of adult patients affiliated with the institutional prepaid health plan active in March 2020, diagnosed with T2DM and established CVD, was included. Data were collected from the Electronic Health Record. The proportion of pharmacological adequacy (combined use of metformin plus sodium-glucose co-transporter 2 inhibitors and/or glucagon-like peptide 1 receptor agonists) was reported along with its respective 95% confidence interval (CI). Results: A total of 1539 patients were included, with a mean age of 76.2 years; 65.3% were male, and 81.6% were overweight or obese. Hemoglobin A1c levels were recorded in the past year for 74.9% of patients, with an average value of 6.9% (SD 1.2). The most prescribed drugs were metformin (61.3%), insulin (26.7%), and gliptins (11%). Out of the total included patients, 82 exhibited pharmacotherapeutic adequacy for diabetes treatment, with a prevalence of 5.3% (95% CI 4.2-6.5). Conclusions: The prevalence of prescribing anti-diabetic drugs with evidence of cardiovascular benefit was 5.3% (95% CI 4.2-6.5). This real-world evidence highlights the low frequency of prescribing this type of medication at the time of the study in a high cardiovascular risk population.

Objetivo: Estimar la proporción de personas con Diabetes Mellitus tipo 2 (DM2) y Enfermedad Cardiovascular (ECV) establecida que reciben tratamiento farmacológico anti-diabético con evidencia de beneficio cardiovascular en un hospital en Argentina. Materiales y Métodos: Estudio de corte transversal realizado en el Hospital Italiano de Buenos Aires. Se incluyó una muestra consecutiva de pacientes adultos afiliados a prepaga institucional activos a Marzo 2020, con diagnóstico de DM2 y ECV establecida. Los datos se tomaron de la Historia Clínica Electrónica. Se informó la proporción de adecuación farmacológica (uso combinado de metformina más inhibidores del cotransportador de sodio glucosa tipo 2 y/o agonistas del Péptido Similar al Glucagón tipo 1) con su respectivo IC95%. Resultados: Se incluyeron 1539 pacientes, con una media de edad 76,2 años, 65,3% eran de sexo masculino, 81,6% con sobrepeso u obesidad. Un 74,9% de los pacientes tenían registro de hemoglobina glicosilada en el último año, con un valor promedio de 6,9% (DE 1,2). Las drogas más prescritas fueron: metformina (61,3%), insulina (26,7%), y gliptinas (11%). Del total de pacientes incluidos, 82 presentaron adecuación fármaco-terapéutica antidiabética, con una prevalencia de 5,3% (IC95% 4,2-6,5). Conclusiones: La prevalencia de prescripción de drogas antidiabéticas con evidencia de beneficio cardiovascular fue de 5,3% (IC95% 4,2-6,5). Esta información extraída de evidencia del mundo real identifica la baja frecuencia de prescripción de este tipo de fármacos al momento del estudio en una población de alto riesgo cardiovascular.

Efficacy of an educational intervention in the management of an inhalation device among nursing professionals of an emergency department.

OBJECTIVE: To explore the most frequent errors of the inhalation technique (main topic for the pharmacological treatment of exacerbations of asthma and/or chronic obstructive pulmonary disease) in the nursing staff of an emergency department, and to evaluate the efficacy of an educational intervention. METHODS: Prospective quasi-experimental study, carried out in a hospital in Argentina during 2019. For the evaluation of the nursing staff, the steps of the Separ-Alat Consensus were used. The educational intervention consisted of oral explanation and visual demonstration of the inhalation technique. Paired data analysis was performed, and absolute and relative frequencies were calculated with their respective 95% confidence intervals. RESULTS: A consecutive sample of 72 nurses was included, of which 95.83% (95%CI 88.30-99.13) made at least one error in the baseline assessment. The most frequent errors were the lack of indication to the patient to exhale prior to inhalation (83.72%), forgetting to remove the air chamber and repeat the steps before the second dose (81.40%). After immediate evaluation after receiving the educational intervention, 74.42% (95%CI 58.83-86.49) corrected the technique. However, at one month, 53.49% (23/43; 95%CI 37.66-68.86) performed the technique correctly. CONCLUSIONS: The educational intervention could be effective in correcting errors in this practice, although its effects tend to fade over time. Therefore, we consider periodic and systematic education relevant to maintain a correct inhalation technique among professionals.

[Participatory Action Research on perceptions, concerns and needs of health professionals in an emergency department from Argentina]. / Investigación-Acción Participativa sobre percepciones, preocupaciones y necesidades de los profesionales de salud en una central de emergencias de Argentina.

INTRODUCTION: To explore perceptions, concerns and needs of healthcare professionals in an emergency department (ED) from Argentina. METHODS: Participatory action research, coordinated and carried out by ED healthcare professionals, which included physicians, nurses and administrative staff who actively engaged in both data collection and analysis. Mixed methodologies were used: documentary analysis of complaints and written claims by patients, 10 individual interviews, and two reflective focus groups of 10 healthcare professionals (who differed in occupation, seniority and experience, including residents in training). RESULTS: The topics that emerged were work factors that lead to errors and threaten patient-centered clinical encounters: work overload and lack of time, the overuse of resources for defensive medicine purposes and technology that replaces physical contact. Healthcare professionals reported episodes of aggression by patients or their families, when long waits and structural insufficiencies (such as lack of beds, saturation of the waiting room, discomfort) threaten patience and tolerance. From these insights, improvements were generated in various areas of the ED. CONCLUSIONS: The identification of problems by the ED stakeholders l was a relevant approach that led to a process of collective management change, promoted reflection and raised awareness, allowing the identification of areas for improvement, design strategies and concrete feasible proposals.

OBJETIVO: Explorar las percepciones, preocupaciones y necesidades del personal de salud en una Central de Emergencias de Adultos (CEA) de Argentina. Métodos: Investigación o acción participativa, coordinada y ejecutada por el propio personal de la CEA, que incluyó médicos/as, personal de enfermería y administrativo/as para participar activamente en la recolección de información y en el análisis. Se utilizaron metodologías mixtas: análisis documental de quejas y reclamaciones escritas por parte de los pacientes, 10 entrevistas individuales y 2 grupos focales reflexivos con 10 integrantes del personal de salud (de diferente cargo y antigüedad, y residentes en formación). RESULTADOS: Los tópicos emergentes fueron factores laborales que inducen al error y atentan contra el encuentro clínico centrado en la persona: la sobrecarga y la falta de tiempo, la sobreutilización de recursos por medicina defensiva y la tecnología que reemplaza el contacto físico. El personal de salud manifestó episodios de agresiones de pacientes o sus familiares, cuando las largas esperas y las insuficiencias estructurales (como falta de camas, saturación de sala de espera, incomodidad) atentan contra la paciencia y la tolerancia. A partir de esta reflexión se generaron mejoras en diversas áreas de la CEA. CONCLUSIONES: La identificación de las problemáticas realizadas por los propios actores de la CEA resultó un método pertinente para generar un proceso de cambio de gestión colectiva, promover la reflexión y concientizar, permitir identificar áreas de mejora, diseñar estrategias y propuestas concretas.

Clinical and Radiographic Outcomes of Percutaneous Third-Generation Double First Metatarsal Osteotomy Combined With Closing-Wedge Proximal Phalangeal Osteotomy for Moderate and Severe Hallux Valgus.

BACKGROUND: The treatment for severe hallux valgus deformity presents a challenge with high risk of complications. Third generation MIS techniques have increased their publications in recent years. The aim was to compare clinical and radiologic outcomes in moderate and severe cases and report minor and major complications. METHODS: Retrospective series of cases with prospective data collection of 156 consecutive feet that underwent percutaneous double first metatarsal osteotomy (PEDO) and first phalanx osteotomy between 2008 and 2019 for moderate (hallux valgus angle [HVA] between ≥20 and <40 degrees and/or intermetatarsal angle [IMA] <16 degrees) and severe (HVA ≥40 degrees and/or IMA ≥16 degrees) hallux valgus deformities. Primary outcomes included radiographic and clinical parameters. Secondary outcomes included minor and major complications. RESULTS: A total of 156 procedures were performed in 128 patients. Mean age was 54.3 years (SD 14.3) (range, 19-82 years), median follow-up was 22.6 months (range, 12-96 months). Radiographic changes pre- to postoperation were as follows: HVA changed from 38.2 (SD 10.1) degrees to 11.2 (SD 8.3) degrees (P < .001), IMA from 14.7 (SD 3.2) degrees to 7.9 (SD 3.7) degrees (P < .001), and distal articular metatarsal angle from 19.7 (SD 6.3) degrees to 8.8 (SD 5.7) degrees (P < .001) after PEDO technique. Clinical changes pre- to postoperation were as follows: American Orthopaedic Foot & Ankle Society ankle-hindfoot scale scores improved from 47.3 (SD 16.5) to 87 (SD 11.6) (P < .001) and visual analog scale scores from 5 (2.7) to 0.9 (1.3) (P < .001). The satisfaction rate was 97% in the total sample. Recurrence rate (HVA ≥20 degrees) was 7.7%. Hallux varus (HVA <0 degrees) occurred in 5.8%, acute osteomyelitis in 1.3%, partial avascular necrosis in 0.6%, screw removal in 0.6%, and reoperation in 1.9%. No nonunion was observed. CONCLUSION: Clinical and radiographic parameters improved significantly, with a minimum of 12 months of follow-up in moderate and severe hallux valgus. Long experience in percutaneous surgery and specific instruments are needed for this technique. Recurrence was linked to preoperative HVA ≥40 degrees and postoperative tibial sesamoid position; Hallux varus was linked to lateral soft tissue release. LEVEL OF EVIDENCE: Level IV, case series.