Intra­ and Interobserver Reliability of Yamaguchi's Method for the Assessment of First Metatarsal Pronation in Hallux Valgus Deformity.

Pronation of the first metatarsal is a risk factor for the formation and progression of the hallux valgus deformity. Recently, Yamaguchi et al published a study that showed how the round sign increases on digitally reconstructed radiography taken from a CT scan when pronation is applied. In this study, the shape of the lateral edge of the first metatarsal head was evaluated on weightbearing dorsoplantar radiographs. Yamaguchi's signs were presented to observers after the visual presentation of each foot as an image. The best-fit circle was drawn using the PACS drawing function. Ninety radiographs of adults presenting hallux valgus deformities were classified as mild-to-moderate, based on hallux valgus angle and intermetatarsal angle. The global average observations were 3.72 ± 3.92 (range 2.3°-4.6°). The interclass correlation (Fleiss Kappa index κ = 0.225) and the Spearman correlation (0.16 of Kappa) coefficients were poor for interobserver measurements and statistically significant. Using the linear model, there was no significant variability between the repetitions corresponding to each observer (t-value -1.527, p value .127). Our findings show that the Yamaguchi method can be very subjective and should not be the exclusive technique to assess the rotation of the first metatarsal or head roundness.

Pesquisa de hábitos alimentarios y factores de riesgo cardiovasculares en adultos en Isla Santiago, Buenos Aires / Survery of dietary habits and cardiovascular risk factors in adults of Isla Santiago, Buenos Aires

Introducción: Existe evidencia acerca de la estrecha relación entre las enfermedades crónicas no transmisibles, los hábitos alimentarios y la actividad física. Sobre el marco de los resultados de la 4ta. Encuesta Nacional de Factores de Riesgo (ENFR), se buscó un territorio isleño de la provincia de Buenos Aires, donde se suponía que el modo de vida podría influir positivamente. Objetivos: analizar la frecuencia de hábitos, la frecuencia de patologías crónicas y la relación entre estas; asumiendo que un estilo de vida alejado de las grandes ciudades llevaría a hábitos más saludables, y con ello, a mejores indicadores de salud. Material y métodos: Estudio de prevalencia. Pesquisa casa por casa sobre 42 hogares en Isla Santiago, donde se aplicó una encuesta y un examen físico, el cual incluyó: medidas antropométricas, presión arterial y glucemia capilar. Resultados: La mayoría de las viviendas (71,4%) tenían, al momento de la recolección de datos, árboles frutales o huerta en sus domicilios. Sin embargo, al realizar la comparación con la 4ta. ENFR, los resultados mostraron que se trataba de una población en la que la inactividad física, la mala alimentación y el consumo problemático de alcohol y tabaco superaba la media nacional. Las enfermedades crónicas resultaron con una tendencia similar a la nacional. Conclusiones: Si bien la accesibilidad a los recursos debe considerarse un elemento importante, esta característica se suma a otros por factores asociados como los socioculturales, la publicidad y aspectos sobre educación para la salud. Se destaca la importancia de trabajar profundamente en los hábitos poblacionales, así como hacer énfasis en la necesidad de implementar programas educativos eficientes y con una mirada loca

Introduction: There is evidence about the close relationship between chronic non-communicable diseases, eating habits and physical activity. Based on the results of the 4th National Survey of Risk Factors (ENFR), an island territory in the province of Buenos Aires was sought where it was assumed that the way of life could have a positive influence. Objectives: to analyze the frequency of habits, the frequency of chronic pathologies and the relationship between them; assuming that a lifestyle away from the big cities would lead to healthier habits, and with it, better health indicators. Material and methods: Prevalence study. A house-to-house survey of 42 homes on Santiago Island, where a survey and physical examination were applied, which included: anthropometric measurements, blood pressure, and capillary blood glucose. Results: Most of the dwellings (71.4%) had fruit trees or orchards in their homes at the time of data collection. However, when making the comparison with the 4th ENFR, the results showed that it was a population in which physical inactivity, poor diet and problematic consumption of alcohol and tobacco exceeded the national average. Chronic diseases resulted in a trend similar to the national one. Conclusions: Although accessibility to resources should be considered an important element, this characteristic is added to others due to associated factors such as sociocultural, advertising and aspects of health education. The importance of working deeply on population habits is highlighted, as well as emphasizing the need to implement efficient educational programs with a local perspective

Efecto de los factores relacionados al cuidado de la diabetes mellitus tipo 2 y motivos de no adhesión en Argentina / Effect of factors related to the care of type 2 diabetes mellitus and reasons for non-adherence in Argentina

Introducción: analizar la injerencia de la adherencia al tratamiento en la evaluación clínica optimiza el uso de pruebas y evita intensificar tratamientos que pueden aumentar riesgos en los pacientes. Conocer sobre las variables influyentes implica el conocimiento y el control de factores relativos al cuidado de la diabetes mellitus tipo 2 (DM2). Objetivos: analizar el efecto de la adherencia al tratamiento en adultos con DM2 en Argentina. Materiales y métodos: estudio transversal. Se incluyeron 1.520 pacientes adultos con DM2 con tres o más meses de antigüedad de enfermedad residentes en Argentina. Se aplicó un cuestionario validado autorreferido. Se evaluó el grado de adherencia reportada, las recomendaciones dadas por el equipo de salud, las formas de adhesión y los motivos de incumplimiento por medio del Summary of Diabetes Self-Care Activities (SDSCA). Resultados: representando diferentes regiones geográficas, la media de adherencia general para todas las características fue 4,32 (61,71%); los peores puntajes para la adherencia correspondieron a la actividad física, el monitoreo glucémico y la dieta en orden ascendente. Se observaron carencias en las recomendaciones por parte del equipo de salud al momento de indicar medidas higiénico dietéticas. Conclusiones: los resultados nacionales observados guardan similitud en la dieta, la actividad física y la disminución en el consumo de tabaco con respecto a los datos prevalentes proveniente de la Cuarta Encuesta Nacional de Factores de Riesgo

Introduction: analyzing the interference of adherence to treatment in clinical evaluation optimizes the use of tests and avoids intensifying treatments that may increase risks in patients. Knowing about the influential variables implies the knowledge and control of factors related to the care of diabetes mellitus type 2 (T2D). Objectives: to analyze the effect of adherence to treatment in adults with T2D in Argentina. Materials and methods: transversal study. We included 1.520 adult patients with T2D with 3 or more months of illness in Argentina. A validated self-reported questionnaire was applied. The degree of adherence reported, the recommendations given by the health team, the forms of adherence and the reasons for non-compliance through the Summary of Diabetes Self-Care Activities (SDSCA) were evaluated. Results: representing different geographical regions, the mean of general adherence for all the characteristics was 4.32 (61.71%); the worst scores for adherence corresponded to physical activity, glycemic monitoring and diet in ascending order. There were shortcomings in the recommendations by the health team when indicating hygienic dietary measures. Conclusions: the observed national results are similar in diet, physical activity and the decrease in tobacco consumption with respect to prevailing data from the Fourth National Survey of Risk Factors.

Calidad de vida y prestaciones en salud de pacientes con diabetes mellitus tipo 2 según región geográfica en Argentina / Quality of life and health benefits in patients with type 2 diabetes according to geography region in Argentina

Introducción: la adherencia al tratamiento de la diabetes mellitus tipo 2 (DM2) en el adulto es un tema complejo y multifactorial que aúna aspectos propios de la enfermedad como no propios, los cuales impactan en la calidad de vida. En Argentina se presentan grandes dificultades al costear la totalidad del tratamiento de la enfermedad. El impacto del ingreso sobre el gasto en salud en DM2 es mayor para los niveles más bajos de ingresos. Objetivos: analizar en adultos con DM2 en Argentina diferencias en variables de calidad de vida y objetivos metabólicos según regiones geográficas y prestación en salud; conocer el gasto de bolsillo en salud y los costos en salud vinculados a DM2; establecer la asociación entre el gasto de bolsillo con variables socioeconómicas y el cumplimiento de los objetivos metabólicos. Materiales y métodos: sobre ocho regiones geográficas de la República Argentina se incluyeron 1.520 pacientes adultos con DM2 y se los clasificó según prestación en salud (sin prestación, con prestación o jubilados). Se aplicó cuestionario validado autorreferido. Resultados: se encontraron diferencias significativas por región geográfica para jubilación prematura por DM2, pérdida de percepción de calidad de vida y cumplimiento de los objetivos metabólicos. Se encontró significancia estadística del gasto de bolsillo con la presencia de subsidio familiar, la jubilación prematura por DM2 y el cumplimiento de los objetivos metabólicos. Conclusiones: se observó disparidad entre las variables de calidad de vida, el gasto en salud y la percepción de subsidios

Introduction: adherence to treatment of diabetes mellitus type 2 (DT2) in the adult is a complex and multifactorial issue that combines aspects of the disease as not own, which impact on the quality of life. In Argentina there are great difficulties in paying for the entire treatment of the disease. The impact of income on health spending in DT2 is greater for lower income levels. Objectives: to analyze differences in quality of life and metabolic objectives according to geographic regions and health benefits in adults with DT2 in Argentina; know the out of pocket expenses in health and health costs linked to DT2; establish an association between out of pocket spending with socioeconomic variables and compliance with metabolic objectives. Materials and methods: over eight geographic regions of the Argentine Republic, 1.520 adult patients with DT2 were classified according to health benefit (without benefit, with benefits or retirees). Validated self-reported questionnaire was applied. Results: significant differences were found by geographic region for premature retirement due to DT2, the loss of perception of quality of life and the fulfillment of metabolic objectives. Statistical significance of out-of-pocket spending was found with the presence of family allowance, early retirement by DT2 and compliance with metabolic objectives. Conclusions: disparity between the variables of quality of life, health expenditure and perception of subsidies was observed

Adherencia al tratamiento en pacientes con diabetes mellitus tipo 2 en Argentina durante 2015 / Adherence to treatment in patients with type 2 diabetes melltius in Argentina during 2015

Introducción: la interrupción en la adherencia a los tratamientos prescriptos genera obstáculos importantes los cuales impactan negativamente en los indicadores de salud. Objetivos: evaluar la adherencia al tratamiento en pacientes adultos con diabetes mellitus tipo 2 (DM2) en Argentina, y establecer la asociación con el tipo de prestación de atención en salud y la ubicación geográfica. Materiales y métodos: se incluyeron 1.520 individuos pertenecientes a ocho regiones diferentes de la República Argentina durante 2015. Se realizó un estudio transversal. Se aplicó un cuestionario validado autorreferido de opciones múltiples con respuestas policotómicas de puntuación simple. Se empleó una escala cuantitativa y un análisis multivariado de componentes principales. Resultados: la edad media fue de 60,2 años y la antigüedad de DM2 referida correspondió a 10,1 años. La media de HbA1c fue de 7,85%. La media de adherencia general para todas las características fue 4,32 (61,71%). Los resultados de adherencia encontrados se asemejan a otros países en desarrollo a excepción del cuidado de los pies. El factor cuidado de los pies en nuestro país reporta escalas de mayor adherencia. Se detectaron resultados tal vez redundantes como la mayor adherencia al monitoreo en las terapias de uso con insulina, y menores para dieta, ejercicio y solo uso de antidiabéticos orales (ADO), así como también la mayor adherencia en medicación en las terapias con insulina e insulina más ADO. Conclusiones: son alarmantes las bajas escalas referidas al grupo con solo dieta y ejercicio

Introduction: the interruption in the adherence to the prescribed treatments generates important obstacles which negatively impact on health indicators. Objectives: to evaluate adherence to treatment in adult patients with diabetes mellitus type 2 (DT2) in Argentina; associate with the type of health care provision and location. Materials and methods: we included 1.520 individuals belonging to eight different geographical regions of the Argentine Republic during 2015. A cross-sectional study was conducted. A self-reported validated questionnaire of multiple options with simple scoring polycotomic responses was applied. A quantitative scale and a multivariate analysis of main components were applied. Results: the average age was 60.2 years and the seniority of the referred DT2 corresponded to 10.1 years. The average HbA1c was 7.85%. The average general adherence for all characteristics was 4.32 (61.71%). The adherence results found are similar to other developing countries except for the care of the feet. The care factor of the feet in our country report scales of greater adherence. Redundant results are observed, such as greater adherence to monitoring in insulin therapy and less for diet and exercise and only oral antidiabetic drugs (ADO), as well as greater medication adherence in insulin and insulin therapies more ADO. Conclusions: the low scales referred to the group with only diet and exercise are alarming

Survival Time to Biopsy-Proven Acute Rejection and Tacrolimus Adverse Drug Reactions in Pediatric Liver Transplantation.

BACKGROUND: Despite advances in surgical procedures and the optimization of immunosuppressive therapies in pediatric liver transplantation, acute rejection (AR) and serious adverse drug reaction (ADR) to tacrolimus still contribute to morbidity and mortality. Identifying risk factors of safety and efficacy parameters may help in optimizing individual immunosuppressive therapies. This study aimed to identify peritransplant predictors of AR and factors related to the risk of ADR to tacrolimus in a large Latin American cohort of pediatric liver transplant patients. METHODS: We performed a retrospective cohort study in a pediatric liver transplant population (n = 72). Peritransplant variables were collected retrospectively including demographic, clinical, laboratory parameters, genomic (CYP3A5 donor and recipients polymorphism), and tacrolimus trough concentrations (C0) over a 2-year follow-up period. Variability in tacrolimus C0 was calculated using percent coefficient of variation and tortuosity. ADR- and AR-free survival rates were calculated using the Kaplan-Meier method, and risk factors were identified by multivariate Cox regression models. RESULTS: Cox-proportional hazard models identified that high tortuosity in tacrolimus C0 was associated with an 80% increased risk of AR [hazard ratio (HR), 1.80; 95% confidence interval (CI), 1.01-3.22; P < 0.05], whereas steroid in maintenance doses decreased this risk (HR, 0.56; 95% CI, 0.31-0.99; P < 0.05). Forty-six patients experienced at least one ADR including hypomagnesemia, nephrotoxicity, hypertension, malignancies, and tremor as a first event. Multivariate analysis showed that C0 values 10 days before the event (HR, 1.25; 95% CI, 1.21-1.39; P < 0.0001) and CYP3A5 expresser recipients (HR, 2.05; 95% CI, 1.03-4.06; P < 0.05) were independent predictors of ADR. CONCLUSIONS: Tacrolimus C0 values, its variability, and CYP3A5 polymorphisms were identified as risk factors of AR and tacrolimus ADR. This knowledge may help to control and reduce their incidence in pediatric liver transplant patients. Prospective studies are important to validate these results.

La contemporización biliar percutánea como estrategia en el tratamiento de la lesión quirúrgica de la vía biliar / Percutaneous biliary interventon as an inital treatment for injury of the bile duct

Antecedentes: El drenaje biliar percutáneo (DBP) se ha utlizado para tratar lesiones quirúrgicas de la vía biliar y como complemento de la cirugía de reparación. Objetivo: Presentar los resultados del drenaje biliar percutáneo en una serie consecutiva de pacientes con lesiones quirúrgicas o secuelas de reparaciones quirúrgicas de la vía biliar. Material y Métodos: Se analizaron los pacientes tratados inicialmente mediante DBP. Se utlizó la cla-sificación de Strasberg y se registró: tpo de operación, vía de abordaje, número de reintervenciones, intentos de reparación biliar y presentación clínica. En los pacientes con continuidad bilioentérica, la primera opción fue el tratamiento percutáneo. Se evaluó el DBP en el pre, intra y postoperatorio y pre dilatación percutánea Resultados: En el hospital Argerich, período 2000 a 2014, se incluyeron 76 enfermos, 68.4% mujeres y post colecistectomía 97%. El 77,6% fueron lesiones Tipo E2 a E5. El porcentaje de enfermos con control de síntomas pre cirugía o dilatación percutánea fue: ictericia 59%, colestasis 5%, colangits 91%, fistula biliar 87%, prurito 90%, retro del hepaticostoma o Kehr 91%. En 13 de 16 pacientes con fistula biliar externa se internalizó el catéter biliar a la cavidad abdominal. En el 70% de 52 pacientes operados, el catéter facilitó la identificación de la vía biliar proximal. En el postoperatorio, no hubo fistulas biliares de la anastomosis bilioentérica, y se detectaron 3 pacientes con estenosis biliar residual y 2 con segmentos biliares aislados que fueron tratados. Conclusión: El DBP resulta útl en el preoperatorio, intraoperatorio y postoperatorio de los pacientes con lesiones quirúrgicas biliares.

Background: Percutaneous biliary drainage (PtibD) has been used to treat surgical bile duct injuries and as an adjunct to repair surgery. Objective: To present the results of PtidB in a consecutive series of patents with surgical injuries or sequelae of surgical repairs of the bile duct. Material and methods: Patents initally treated with PtibD were analyzed. Strasberg classificaton was used and recorded: type of operaton, surgical approach, number of reoperatons, biliary repair atempts and clinical presentaton. In patents with bilioenteric continuity, percutaneous biliary treatment was the frst opton. PtibD was evaluated in the pre, intra and postoperative period and in the pre dilataton period. Results: At the Hospital Argerich, from 2000 to 2014, 76 patents were included, 68.4% women and 97% post cholecystectomy. The lesions were Type E2 to E5 in 77% of cases. The percentage of patents with controlled symptoms before surgery or percutaneous dilataton was: jaundice 59%, cholestasis 5%, cholangits 91%, biliary fistula 87%, pruritus 90%, withdrawal hepaticos-toma or T-Kehr 91%. In 13 of 16 patents with external biliary fistula, the catheter could be internalized to abdominal cavity. In 70% of 52 operated patents, the catheter facilitated the identificaton of the proximal biliary duct. In the postoperative period, there were no biliary fistulas of the bilioenteric anastomoses and 3 patents with residual biliary stenosis and 2 with isolated biliary segments were detected and treated. Conclusion: PtibD is helpful in the pre, intra and postoperative treatment of patents with surgical bile duct injuries.

Estimación del riesgo de somatización en pacientes hipertensos / Estimation of the Risk of Somatization in Hypertensive Patients

Introducción: La somatización en el paciente hipertenso afecta no solo su calidad de vida, sino también su adherencia al tratamiento y la relación médico-paciente, constituyéndose en un problema sanitario de alto costo, por lo que la posibilidad de determinar el riesgo de somatizar en estos pacientes podría favorecer un manejo individualizado de sus manifestaciones. Objetivos: Estratificar en una cohorte de hipertensos esenciales el riesgo de somatización y caracterizar las variables hemodinámicas asociadas. Material y métodos: Se analizaron de manera prospectiva 120 individuos que asistieron para la evaluación de su riesgo cardiovascular, que se clasificaron en: 1) grupo de hipertensos controlados (HTC) (57%, n = 68) y 2) grupo control de normotensos (NT) (43%, n = 52). El riesgo de somatización se evaluó con el inventario de síntomas SCL-90-R y las escalas de depresión y ansiedad. El perfil hemodinámico se determinó con un método oscilométrico validado. Resultados: El riesgo de somatización fue más elevado en el grupo HTC de manera independiente de la presencia de otras alteraciones emocionales. Los individuos con mayor riesgo de depresión y/o ansiedad presentaron mayor evidencia de somatización (p < 0,0001). En los HTC tratados (n = 38) se observó mayor riesgo de somatización y de trastornos del sueño respecto de los HTC sin tratamiento. El índice de masa corporal se asoció con el riesgo de somatización (p = 0,0227) y el género femenino mostró que es predictivo de somatización, ansiedad y depresión (p = 0,001). Se observó una relación directa entre el gasto cardíaco y depresión y somatización y entre el riesgo de somatización y el producto de la frecuencia cardíaca por la presión arterial sistólica en reposo. Conclusiones: Los resultados muestran la factibilidad de estimar el riesgo de somatización a través de una herramienta validada y reproducible. Los síntomas de consulta frecuente en esta condición podrían estar asociados con un riesgo incrementado de somatización, especialmente vinculado al género femenino, el índice de masa corporal, el tratamiento farmacológico, la presencia de alteraciones emocionales como depresión y ansiedad y el patrón hiperdinámico.

Background: Somatization in hypertensive patients affects not only their quality of life but also their adherence to treatment and the physician-patient relationship, constituting an expensive health care issue. The possibility of estimating the risk of somatization in these patients could promote an individualized management of their manifestations. Objectives: The goal of this study was to stratify the risk of somatization in a cohort of patients with essential hypertension and to characterize the hemodynamic variables associated with the risk of somatization in hypertensive patients. Methods: A total of 120 subjects undergoing cardiovascular risk assessment were prospectively analyzed and classified in: 1) controlled hypertensive group (CHT) (57%, n=68) and 2) normotensive group (NT) (43%, n=52). The risk of somatization was evaluated using the SCL-90-R symptom ckecklist, and the anxiety and depression scales. The hemodynamic profile was determined using a validated oscillometric method. Results: The risk of somatization was higher in the CHT group independently of the presence of other emotional disorders. In subjects with higher risk of depression or anxiety, the evidence of somatization was greater (p<0.0001). In the CHT group, those who received treatment (n=38) had greater risk of somatization and of sleep disorders compared to those without treatment in the same group. Body mass index was associated with the risk of somatization (p=0.0227) and female sex was a predictor of somatization, anxiety and depression (p=0.001). A direct relationship was observed between cardiac output and depression and somatization, and between the risk of somatization and the product of heart rate and systolic blood pressure at rest. Conclusion: The estimation of the risk of somatization is feasible using a validated and reproducible tool. The frequently consulted symptoms in this condition could be associated with a higher risk of somatization, particularly linked with female sex, body mass index, drug therapy, presence of emotional abnormalities a depression and anxiety, and an hyperdynamic pattern.

Characterization of the cortisol stress response to sedation and anesthesia in children.

CONTEXT: The cortisol stress response to sedation and anesthesia in children is not well characterized. It is not clear whether it is necessary to give stress doses of corticosteroids to children with adrenal insufficiency undergoing sedated procedures. OBJECTIVE: Our objective was to describe the cortisol stress response to sedation and anesthesia in normal children. DESIGN, SETTING, AND PATIENTS: This was a prospective cohort study of 149 children ages 1 month to 17 yr who presented for routine sedated procedures. Salivary cortisol was measured at baseline, every 30 min during procedures, at completion, and at recovery. MAIN OUTCOME MEASURES: We evaluated relative change in salivary cortisol from baseline for level of sedation achieved and type of procedure performed. RESULTS: In total, 117 patients had adequate samples collected, and 110 were included in the main analysis. Twenty-five percent of patients showed an increase in salivary cortisol greater than four times baseline, consistent with a stress response. Mean salivary cortisol increased more than 3-fold from baseline (3.7±0.4, P<0.001) for all patients in the study. There was no difference for change in cortisol when comparing by level of sedation achieved or by type of procedure performed. The majority of patients with a stress response had their highest levels in the recovery phase, after their procedure was completed. CONCLUSION: Sedation and anesthesia can induce a significant rise in cortisol in children. Additional studies should be performed to validate our results and to determine whether stress dosing of corticosteroids may be needed for children with adrenal insufficiency undergoing sedated procedures.