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.

Short sleep and low milk intake are associated with obesity in a community of school aged children from Argentina.

OBJECTIVES: Understanding the factors related to obesity during childhood allows for improved preventive actions specifically adapted to particular communities. The purpose of this study was to identify individual and familiar factors related to obesity in children. METHODS: A cross-sectional study was conducted in an urban community in Argentina during the years 2015-2016. Weight and height were measured on a probabilistic sample of 1366 schoolchildren aged 6 to 12 years. BMI categories were established according to International Obesity Task Force (IOTF) cut-offs. Data were analyzed using multivariate and logistic regression models. Independent variables corresponded to four domains: anthropometric, socioeconomic and demographic, nutritional, and energy balance. RESULTS: Twenty percent of children were categorized as overweight (OW) and 12.2% were obese (OB). Parental IOTF grade was positively associated with childhood OW/OB (father B = 0.421 P = 0.000, OR = 1.52, 95% CI 1.24-1.88; mother B = 0.498 P = 0.000, OR = 1.65, 95% CI 1.37-1.97). The remaining variables were negatively associated with OW/OB: hours of sleep (B = -0.566 P = 0.001, OR = 0.57, 95% CI 0.41-0.79), physical activity (B = -0.362 P = 0.017, OR = 0.70, 95% CI 0-52-0.94), and daily milk intake (B = -0.178 P = 0.045, OR = 0.84, 95% CI 0.70-0.99). Parental IOTF predicted both OW and OB, while sleep hours predicted OW and physical activity predicted OB. CONCLUSIONS: Family should be considered the initial target for effective strategies to reduce obesity. Like physical activity, the promotion of milk and dairy intake, as well as sleep, may have a major role in obesity reduction because of their protective effects in this community.

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.

Retention of pediatric resuscitation performance after a simulation-based mastery learning session: a multicenter randomized trial.

OBJECTIVES: Using simulation-based mastery learning, residents can be trained to achieve a predefined performance standard in resuscitation. After mastery is achieved, performance degradation occurs over time. Prior investigations have shown performance retention of 12-14 months following intensive simulation-based mastery learning sessions. We sought to investigate the duration of mastery-level resuscitation performance retention after a single 1- to 2-hour simulation-based mastery learning session. DESIGN: Randomized, prospective trial. SETTING: Medical simulation laboratory. SUBJECTS: Convenience sample of 42 pediatric residents. INTERVENTIONS: Baseline resuscitation performance was determined on four standardized simulation scenarios. After determination of baseline performance, each resident repeated each scenario, as needed, until mastery-level performance was achieved. Residents were then randomized and retested 2, 4, or 6 months later. Statistical analysis on scores at baseline and retesting were used to determine performances changes from baseline and performance retention over time. MEASUREMENTS AND MAIN RESULTS: Forty-two residents participated in the study (12 in 2 mo group, 14 in 4 mo group, and 16 in 6 mo group). At baseline, postgraduate year-3 residents performed better than postgraduate year-1 residents (p = 0.003). Overall performance on each of the four scenarios improved at retesting. The percent of residents maintaining mastery-level performance showed a significant linear decline (p = 0.039), with a drop at each retesting interval; 92% retained mastery at 2 months, 71% at 4 months, and 56% at 6 months. There was no difference in retention between postgraduate year-1, postgraduate year-2, and postgraduate year-3 residents (p = 0.14). CONCLUSIONS: Residents displayed significant improvements in resuscitation performance after a single simulation-based mastery learning session, but performance declined over time, with less than 60% retaining mastery-level performance at 6 months. Our results suggest that relatively frequent refresher training is needed after a single simulation-based mastery learning session. Additional research is needed to determine the duration of performance retention following any specific simulation-based mastery learning intervention.

Changing etiologies and outcomes of acute liver failure: perspectives from 6 transplant centers in Argentina.

There is significant geographic variation in the etiologies and prognoses of acute liver failure (ALF). The aims of the present study were to determine the causes and short-term outcomes of ALF in Argentina, to evaluate the performance of prognostic criteria, and to identify clinical prognostic factors of death. We performed a retrospective analysis of 154 adult patients with ALF who were admitted to 6 liver transplantation (LT) programs between June 2005 and December 2011. The most frequent causes of ALF were viral hepatitis B (46 patients or 30%), autoimmune hepatitis (AIH; 40 patients or 26%), and indeterminate causes (40 patients or 26%). No acetaminophen (ACM) overdose was reported. One hundred and twenty one patients (78%) were included on the waiting list, and LT was performed for 83 patients (54%). Overall survival rate is now corected to 73%. Multivariate logistic regression identified 2 independent variables associated with adverse outcomes on admission: a Model for End-Stage Liver Disease (MELD) score ≥ 29 and an encephalopathy grade ≥ 3. In a direct comparison using a receiving operating characteristic curve analysis, the MELD score [C statistic = 0.830, 95% confidence interval (CI) = 0.73-0.93] had better prognostic accuracy for predicting outcomes than the Clichy criteria (C statistic = 0.719, 95% CI = 0.58-0.85) or the King's College criteria (C statistic = 0.631, 95% CI = 0.49-0.77). In conclusion, hepatitis B and AIH were the most frequent causes of fulminant hepatic failure in our series, and no cases of ACM overdosing were identified. A MELD score ≥ 29 and an encephalopathy grade ≥ 3 at admission were associated with death. The MELD score at admission showed the highest prognostic accuracy.

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.

Total and acylated ghrelin levels in children with poor growth.

Ghrelin, an enteric hormone with potent appetite stimulating effects, also stimulates growth hormone release. We hypothesized that altered levels of total ghrelin (TG) or acylated ghrelin (AG) could affect growth by altering growth hormone secretion, subsequently affecting insulin-like growth factor-1 (IGF-1) generation or by altering appetite and food intake. After institutional review board approval, 52 children presenting for evaluation of chronic gastrointestinal symptoms (group 1), poor weight gain (group 2), or poor linear growth (group 3) were evaluated for fasting TG and AG levels in addition to their regular evaluation. Serum ghrelin, IGF-1, and prealbumin were compared between groups. No difference was observed for mean fasting TG between groups. However, mean fasting AG was highest in patients in group 2 (465 ± 128 pg/mL) versus group 1 (176 ± 37 pg/mL) and group 3 (190 ± 34 pg/mL). IGF-1 was lowest in patients in group 2 despite similar prealbumin levels among the three groups. We conclude that serum AG levels are highest in children with isolated poor weight gain compared with children with short stature or chronic gastrointestinal symptoms, suggesting the possibility of resistance to AG in underweight children. Additional studies are needed to further clarify ghrelin's role in growth and appetite.

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

Concurrent use of metered-dose and dry powder inhalers by children with persistent asthma does not adversely affect spacer/inhaler technique.

BACKGROUND: Studies conducted in adults have suggested that patients who use a metered-dose inhaler/holding chamber spacer (MDI/S) and dry powder inhaler (DPI) concurrently will have poorer MDI/S technique than that of patients who use MDI/S exclusively. To our knowledge, as of August 31, 2006, no studies have been performed in pediatric patients. OBJECTIVE: To compare MDI/S technique scores of children using only MDI/S with scores of those using both MDI/S and DPIs. METHODS: The MDI/S technique of children aged 6-17 years, with persistent asthma, recruited from a general pediatric practice population for an asthma intervention study project was scored using a standardized checklist. MDI/S scores of children who were being treated with maintenance and rescue medication delivered only by MDI/S were compared with those treated with both MDI/S (rescue) and DPI (maintenance). Scores lower than 70% were considered to be inadequate. RESULTS: A total of 117 patients (73 male, 44 female), aged 9.70 +/- 3.1 years (mean +/- SD), with persistent asthma, participated in the study. There were 83 children (54 male, 29 female, age 9.4 +/- 3.2 y) in the MDI/S only group and 34 (19 male, 15 female, age 10.3 +/- 2.9 y) in the MDI/S + DPI group. In the MDI/S + DPI group, Diskus was the DPI used for 32 patients, and Turbuhaler was used by 2 children. Sixteen patients had severe persistent asthma, 80 had moderate persistent asthma, and 21 had mild persistent asthma as classified by National Heart Lung and Blood Institute guidelines. No difference in sex and age demographics existed; however, there was a difference in the distribution of asthma severity between groups (ie, no patients with mild persistent asthma in the MDI/S + DPI group; p < or = 0.01). Mean score for the MDI/S only group was 86 +/- 17% and, for the MDI/S + DPI group, 90.1 +/- 12% (p = 0.15). More patients in the MDI/S group had inadequate scores (18%) compared with those in the MDI/S + DPI group (3%; p < 0.05). CONCLUSIONS: While DPI and MDI/S techniques are markedly different in several significant ways, concurrent use of these inhalers did not adversely affect MDI/S technique scores of pediatric patients with persistent asthma, compared with those using MDI/S alone. Patients in the MDI/S only group had an inadequate MDI/S score (<70%) more often than did patients in the MDI/S + DPI group.

An Internet-based store-and-forward video home telehealth system for improving asthma outcomes in children.

The adherence and disease-control outcomes associated with the use of an Internet-based store-and-forward video home telehealth system to manage asthma in children were studied. Pediatric patients with persistent asthma were provided with home computers and Internet access and monitored biweekly over the Internet. All patients were seen in the pediatric clinic at 0, 2, 6, 12, and 24 weeks. Half of the patients received asthma education in person and half via an interactive Web site. Adherence measures were assessed by therapeutic and diagnostic monitoring. Therapeutic monitoring included digital videos of patients using their controller medication inhaler. Diagnostic monitoring included an asthma symptom diary and a video of peak flow meter use. Videos were submitted electronically twice a week by using in-home telemonitoring with store-and-forward technology. Feedback was provided electronically to each patient. Disease control was assessed by examining quality of life, utilization of services, rescue-therapy use, symptom control, satisfaction with home telemonitoring, and retention of asthma knowledge. Patients were randomly assigned to an asthma education group (Internet versus office), and the data were analyzed by comparing results for study days 0-90 and 91-180. Ten children participated. A total of 321 videos of inhaler use and 309 videos of peak flow meter use were submitted. Inhaler technique scores improved significantly in the second study period. Submission of diagnostic monitoring videos and asthma diary entries decreased significantly. Peak flow values as a percentage of personal best values increased significantly. Overall, there was no change in quality of life reported by patients. However, the caregivers in the virtual-education group reported an increase in the patients' quality-of-life survey scores. Emergency department visits and hospital admissions for asthma were avoided. Rescue therapy was infrequent. A high rate of satisfaction with home telemonitoring was reported. Internet-based, store-and-forward video assessment of children's use of asthma medications and monitoring tools in their homes appeared effective and well accepted.

Report of the first annual Hawaii Asthma Research Consortium.

The first Hawaii Asthma Research Consortium was held on 7 May 2001 at Tripler Army Medical Center. Researchers investigating asthma-related problems and program directors of asthma projects were solicited statewide to present their projects. Ten lecturers focused on research and asthma projects in Hawaii in 20-minute presentations. An informal ten-minute discussion followed each presentation to encourage audience questions about the project and to discuss possible collaboration efforts between institutions. The institutions that were represented include: American Lung Association-Hawaii, Kaiser Permanente Center for Health Research Hawaii, Kapiolani Medical Center, Tripler Army Medical Center, University of Hawaii at Manoa, and Waianae Coast Comprehensive Health Center.

Evolution of Framingham cardiovascular risk score in HIV-infected patients initiating EFV- and LPV/r-based HAART in a Latin American cohort.

INTRODUCTION: Epidemiological studies suggest that some antiretroviral drugs may contribute to increase cardiovascular risk in HIV-infected patients. However, data from Latin American countries are limited, as impact of HAART on cardiovascular risk remains understudied. In this context, we aimed to evaluate if 10-year Framingham Cardiovascular Risk Score (FCRS) increases in patients following exposure to EFV- and LPV/r-based HAART in a Latin American cohort. MATERIALS AND METHODS: Retrospective 48-week cohort study. We reviewed clinical charts of randomly selected samples of patients initiating (according to national guidelines) EFV first-line HAART and LPV/r first- or second-line (but first PI-based) HAART assisted at a reference HIV centre in Buenos Aires, Argentina (period 2004-2012). Each patient could only be included in one arm. FCRS was calculated according to National Institutes of Health risk assessment tool (http://cvdrisk.nhlbi.nih.gov/). RESULTS: A total of 357 patients were included: 249 in EFV arm and 108 in LPV/r arm (80 as first line and 28 as second line, but first PI-based HAART). Baseline characteristics (median, interquartile range): age, 38 (33-45) years; male, 247 (69%); viral load, 98200 (20550-306000) copies/mL; CD4 T-cell count, 115 (60-175) cel/µL; total cholesterol, 159 (135-194) mg/dL; HDL: 39 (31-41) mg/dL; LDL: 94 (72-123) mg/dL; current smoker, 29%; on antihypertensive drugs: 14 (4%), diabetic: 4 (1%). Most frequent accompanying nucleoside reverse transcriptase inhibitors (NRTIs) were 3TC (92%) and zidovudine (AZT; 76%). Baseline FCRS was low, moderate and high for 93%, 7% and 0% of patients on EFV arm and 96.7%, 1.7% and 1.7% on LPV/r arm. On EFV arm, an increase in FCRS category (low to moderate or moderate to high) was observed in 1 patient (0.9%) at 24 weeks and 6 (5,6%) at 48 weeks; 5 (4.7%) decreased category. On LPV/r arm no one varied FCRS category at 24 weeks and 2 (3.4%) increased from low to moderate at 48 weeks (no patient decreased FCRS category). Cumulative incidence of overall cardiovascular events was 1.6% on EFV and 1.8% on LPV/r arms respectively. Probability of increasing FCRS category or having a cardiovascular event did not differ between arms at a significance level of 5%. CONCLUSIONS: Probability of increasing FCRS category and cardiovascular events was low and similar in patients exposed to EFV versus LPV/r-based HAART in a Latin American cohort. ClinicalTrials.gov Identifier: NCT01705873.

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

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.

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.

The effectiveness of video-assisted debriefing versus oral debriefing alone at improving neonatal resuscitation performance: a randomized trial.

INTRODUCTION: Debriefing is a critical component of effective simulation-based medical education. The optimal format in which to conduct debriefing is unknown. The use of video review has been promoted as a means of enhancing debriefing, and video-assisted debriefing is widely used in simulation training. Few empirical studies have evaluated the impact of video-assisted debriefing, and the results of those studies have been mixed. The objective of this study was to compare the effectiveness of video-assisted debriefing to oral debriefing alone at improving performance in neonatal resuscitation. METHODS: Thirty residents, divided into 15 teams of 2 members each, participated in the study. Each team completed a series of 3 neonatal resuscitation simulations. Each simulation was followed by a facilitated debriefing. Teams were randomly assigned to receive either oral debriefing alone or video-assisted debriefing after each simulation. Objective measures of performance and times to complete critical tasks in resuscitation were evaluated by blinded video review on the first (pretest) and the third (posttest) simulations using a previously validated tool. RESULTS: Overall neonatal resuscitation performance scores improved in both groups [mean (SD), 83% (14%) for oral pretest vs. 91% (7%) for oral posttest (P = 0.005); 81% (16%) for video pretest vs. 93% (10%) for video posttest (P < 0.001)]. There was no difference in performance scores between the 2 groups on either the pretest or posttest [overall posttest scores, 91.3% for oral vs. 93.4% for video (P = 0.59)]. Times to complete the critical tasks of resuscitation also did not differ significantly between the 2 study groups. The educational effect of the video-assisted debriefing versus oral debriefing alone was small (d = 0.08). CONCLUSIONS: Using this study design, we failed to show a significant educational benefit of video-assisted debriefing. Although our results suggest that the use of video-assisted debriefing may not offer significant advantage over oral debriefing alone, exactly why this is the case remains obscure. Further research is needed to define the optimal role of video review during simulation debriefing in neonatal resuscitation.

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.

A pilot project for improving paediatric diabetes outcomes using a website: the Pediatric Diabetes Education Portal.

We created a website for patients and families that allowed them to review clinic test results, review educational materials related to these results and post questions to their diabetes educator. Fingerstick haemoglobin A(1c) (HbA(1c)) testing and periodic use of a continuous glucose monitoring system (CGMS) were offered to all patients. The HbA(1c) and CGMS results were posted to the website after each clinic visit. A total of 52 patients with type 1 diabetes were enrolled in the study. There were 16 patients with HbA(1c) values within ADA guidelines and 16 with HbA(1c) values above guidelines; 20 patients were excluded for various reasons. Users of the website were defined as families who logged in four or more times over the six-month study period. For patients whose HbA(1c) started above ADA guidelines, the mean HbA(1c) for website users decreased from 10.5% (SD 2.2) at baseline to 9.1% (SD 1.2) after six months. In the non-users, the mean HbA(1c) increased from 9.5% (SD 1.5) at baseline to 10.4% (SD 2.5). However, these changes were not significant. A between groups comparison (users versus non-users) showed a significant improvement in HbA(1c) for website users (P = 0.03). This change in HbA(1c) was clinically relevant. Further studies with more patients are needed to see if these improvements can be sustained over a longer period.

Deliberate practice using simulation improves neonatal resuscitation performance.

INTRODUCTION: Simulation will soon become the standard method of training in the Neonatal Resuscitation Program (NRP). Deliberate practice (DP) using simulation has been shown to improve performance in other areas of medicine. The objective of this study was to evaluate the effectiveness of DP using simulation on improving NRP performance. METHODS: Using a pretest-posttest design, 15 teams of 2 residents participated in a series of 3 NRP simulations followed by a facilitated debriefing. Objective measures of NRP performance and time to complete critical tasks were evaluated on the first (pretest) and the third (posttest) simulations by blinded video review using a validated scoring instrument. RESULTS: Improvements were seen in scores for overall NRP performance (pretest 82.5% vs. posttest 92.5%, mean difference 10% [95% CI, 1.5-18.5]; P = 0.024) and positive-pressure ventilation (pretest 73.3% vs. posttest 95.0%, mean difference 21.7% [95% CI, 0.8-42.5]; P = 0.043). Time to the vascular access decreased by over 1 minute from baseline (pretest 404 second vs. posttest 343 second, mean difference -60.3 second [95% CI, -119.6 to -0.9]; P = 0.047) as did the time to first IV medication (pretest 452 second vs. posttest 387 second, mean difference -64.9 second [95% CI, -112.4 to -17.5]; P = 0.011). CONCLUSIONS: Our results suggest that DP using simulation is associated with improvements in NRP performance and support the use of DP using simulation in NRP training.