Medicine and the metaverse: current applications and future.

Innovative technologies such as the metaverse and chat GPT-4 (based on artificial intelligence) are present in the daily discourse of society; recently, they have been introduced into medical practice and are bringing about important changes. In the case of the metaverse ("beyond the universe"), various medical schools and departments around the world are beginning to use it as an innovative strategy for teaching subjects such as anatomy, histology, ophthalmology, and simulation in parallel (virtual) worlds for learning and supervision of surgeries, as well as for other applications in medical education and in the doctor-patient relationship. Although it should be regarded as an area of opportunity for the transformation of medicine, it is important to consider the various limitations and risks of the metaverse in medical practice, student training, and physicians' relationship with the health problems they have to deal with in their practice.

Las innovadoras tecnologías del metaverso y el chat GPT4 (basado en inteligencia artificial) están presentes en el discurso cotidiano de la sociedad; recientemente se han introducido en la práctica médica y están provocando importantes cambios. En cuanto al metaverso ("después del universo"), diversas escuelas y facultades de medicina del mundo comienzan a utilizarlo como una estrategia innovadora dirigida a la enseñanza de materias como anatomía, histología, oftalmología y simulación en mundos paralelos (virtuales) para el aprendizaje y supervisión de cirugías, así como para otras aplicaciones en educación médica y en la relación médico-paciente. Si bien debe tomarse en cuenta como un área de oportunidad para la transformación de la medicina, es importante considerar las diversas limitaciones y riesgos del metaverso en la práctica médica, la formación de estudiantes y la relación del médico con los problemas de salud a los que se enfrenta en su práctica.

ChatGPT: opportunities and risks in the fields of medical care, teaching, and research.

ChatGPT is a virtual assistant with artificial intelligence (AI) that uses natural language to communicate, i.e., it holds conversations as those that would take place with another human being. It can be applied at all educational levels, including medical education, where it can impact medical training, research, the writing of scientific articles, clinical care, and personalized medicine. It can modify interactions between physicians and patients and thus improve the standards of healthcare quality and safety, for example, by suggesting preventive measures in a patient that sometimes are not considered by the physician for multiple reasons. ChatGPT potential uses in medical education, as a tool to support the writing of scientific articles, as a medical care assistant for patients and doctors for a more personalized medical approach, are some of the applications discussed in this article. Ethical aspects, originality, inappropriate or incorrect content, incorrect citations, cybersecurity, hallucinations, and plagiarism are some examples of situations to be considered when using AI-based tools in medicine.

ChatGPT es un asistente virtual con inteligencia artificial que utiliza lenguaje natural para comunicarse, es decir, mantiene conversaciones como las que se tendrían con otro humano. Puede aplicarse en educación a todos los niveles, que incluye la educación médica, en donde puede impactar en la formación, la investigación, la escritura de artículos científicos, la atención clínica y la medicina personalizada. Puede modificar la interacción entre médicos y pacientes para mejorar los estándares de calidad de la atención médica y la seguridad, por ejemplo, al sugerir medidas preventivas en un paciente que en ocasiones no son consideradas por el médico por múltiples causas. Los usos potenciales del ChatGPT en la educación médica, como una herramienta de ayuda en la redacción de artículos científicos, un asistente en la atención para pacientes y médicos para una práctica más personalizada, son algunas de las aplicaciones que se analizan en este artículo. Los aspectos éticos, originalidad, contenido inapropiado o incorrecto, citas incorrectas, ciberseguridad, alucinaciones y plagio son ejemplos de las situaciones a tomar en cuenta al usar las herramientas basadas en inteligencia artificial en medicina.

[Artificial intelligence in medicine: present and future]. / Inteligencia artificial en medicina: presente y futuro.

Artificial intelligence (AI) promises a significant transformation of health care in all medical areas, which could represent "Gutenberg moment" for medicine. The future of medical specialties came largely from human interaction and creativity, forcing physicians to evolve and use AI as a tool in patient care. AI will offer patients safety, autonomy, and access to timely medical care in hard-to-reach areas while reducing administrative burden, screen time, and professional burnout for physicians. AI will also make it possible to reduce the frequency of medical errors and improve diagnostic accuracy through the integration, analysis, and interpretation of information by algorithms and software. The safety of repetitive activities will free up time for health personnel and will enhance the doctor-patient relationship, return to personalized attention and interaction with the patient, through accompaniment, communication, empathy, and trust during illness, activities that will never be replaced by AI. It is still necessary to standardize research in the area, which allows improving the quality of scientific evidence knowing its advantages and risks, accelerating its implementation in current medical practice.

La inteligencia artificial (IA) promete una transformación significativa del cuidado de la salud en todas las áreas médicas, lo que podría representar el «momento Gutenberg¼ para la medicina. El futuro de las especialidades médicas dependerá en gran medida de la interacción humana y la creatividad, obligando a los médicos a evolucionar y emplear la IA como una herramienta en la atención del enfermo. La IA ofrecerá a los pacientes seguridad, autonomía y posibilidad de atención médica oportuna en zonas de difícil acceso, y a los médicos les ayudará a disminuir la carga administrativa, el tiempo en pantallas y el agotamiento profesional. La IA permitirá también reducir la frecuencia de errores médicos y mejorar la precisión diagnóstica a través de la integración, el análisis y la interpretación de información por algoritmos y software. La automatización de actividades repetitivas liberará tiempo al personal de salud y potencialmente mejorará la relación médico-paciente, regresando a la atención personalizada y la interacción con el enfermo, a través del acompañamiento, la comunicación, la empatía y la confianza durante la enfermedad, actividades que nunca serán reemplazadas por la IA. Aún es necesario estandarizar la investigación en el área, que permita mejorar la calidad de la evidencia científica conociendo sus ventajas y riesgos, y acelerar su implementación en la práctica médica actual.

Severe acute hepatitis of unknown origin.

At the beginning of 2022, in the United Kingdom, and later in several European countries, a group of pediatric patients who developed acute hepatitis of so far unknown origin was reported. Clinical data include nausea, vomiting, jaundice, and liver failure; some patients require liver transplantation. The affected population is younger than 10 years of age. The probable etiological agent is adenovirus genotype F41, and toxic factors have been ruled out, as well as a relationship with COVID-19. There are several theories to explain this phenomenon, which are being investigated.

A inicios de 2022, en Reino Unido, y posteriormente en varios países europeos, se informó sobre un grupo de pacientes pediátricos que desarrollaron hepatitis aguda de origen desconocido hasta ahora. Los datos clínicos consisten en náusea, vómito, ictericia y falla hepática; algunos pacientes necesitan trasplante hepático. La población afectada es menor a los 10 años. El agente etiológico probable es el adenovirus genotipo F41 y se han descartado factores tóxicos, así como la relación con COVID-19. Existen varias teorías para explicar este fenómeno, las cuales se están investigando.

At 50 years of the description of acute respiratory distress syndrome. / A 50 años de la descripción del síndrome de insuficiencia respiratoria aguda.

In 1967, Ashbaugh et al. published in the Lancet the description of a new entity, for which they coined the name "adult respiratory distress syndrome". On that article, they thoroughly described 12 patients who had respiratory distress with bilateral pulmonary infiltrates and oxygen therapy-refractory hypoxemia. For its management, emphasis was made on the importance of intubation and mechanical ventilation with positive end-expiratory pressure. At 50 years of its first publication, great advances on the knowledge of this condition have been achieved, which has influenced on patient management and survival. To celebrate this 50th anniversary, the National Academy of Medicine of Mexico organized a symposium with the purpose to spread the knowledge about this condition, recognize the researchers who made the original description and those who over the course of 50 years of history have contributed to its better understanding. The symposium addressed the topics of lung-kidney interaction, molecular bases of the disease and therapeutic advances.

En 1967, Ashbaugh et al. publicaron en Lancet la descripción de una nueva entidad para la que acuñaron el nombre "síndrome de distress respiratorio del adulto". En ese artículo describieron minuciosamente a 12 enfermos que presentaban insuficiencia respiratoria, con infiltración pulmonar bilateral e hipoxemia resistente a oxigenoterapia. Para su manejo se hizo énfasis en la importancia de la intubación y la ventilación mecánica con presión positiva al final de la espiración. A 50 años de la publicación se han logrado grandes avances en el conocimiento de esta enfermedad, lo que ha influido en el manejo y supervivencia de los pacientes. Para celebrar este cincuentenario, la Academia Nacional de Medicina de México organizó un simposio que tuvo como objetivos difundir el conocimiento de esta enfermedad, reconocer a los personajes que hicieron la descripción original y a quienes en 50 años de historia han contribuido a su mejor entendimiento. El simposio abordó los temas de interacción pulmón-riñón, bases moleculares de la enfermedad y avances en el tratamiento.

[Quantitative evaluation proposal of a ultrasonographic protocol for weaning from mechanichal ventilation]. / Propuesta de evaluación cuantitativa en el protocolo ultrasonográfico para retiro de la ventilación mecánica invasiva (GMEMI score).

INTRODUCTION: Mechanical ventilation is a therapy for vital support used in a significant proportion of critically ill patients. The right time to successfully discontinue this therapy is a challenge for the intensive care specialist. For this reason it is still a subject for research. The echocardiographic evaluation of the diastolic dysfunction, the diaphragm, and the lung have become an invaluable tool for weaning from mechanical ventilation protocols, especially in patients with difficult or prolonged weaning from mechanical ventilation. There is still a need to validate, in controlled trials, the efficacy of an ultrasound protocol for weaning from mechanical ventilation that integrates the three modalities in a single protocol. METHODS: Based on current literature, we developed a score justified by a mathematical model based on inequations. When χ ⇒ 5 the risk of failure in the weaning process rises, the weaning process should be suspended; when χ ⇒ 1 the risk of failure is low, the weaning process should be continued. CONCLUSIONS: The use of math models for decision-making is of great importance, as it sets an objective parameter within the existing evaluations. We proposed the use of inequations to set intervals of solution with the three points of care for ultrasound-guided weaning from mechanical ventilation. With this, the inequations proposed generate an area of certainty within the proposed values and the solution intervals.

Thrombosis and hemorrhage in the critically ill cirrhotic patients: five years retrospective prevalence study.

BACKGROUND: Cirrhotic patients present a complex interaction between deficient synthetic liver function, hemodynamic abnormalities and superimposed conditions that alter coagulation system. This alters both coagulation and fibrinolytic processes,increasing bleeding and thrombosis risks. Particularly, critically ill cirrhotic patients represent a diagnostic challenge since they have multiple comorbidities making the thrombotic and bleeding risks unpredictable. The prevalence of bleeding and thrombosis in this subset of patients remains poorly described. The main aim of this article is to describe the prevalence of thrombotic and hemorrhagic complications in cirrhotic patients admitted between 2007 and 2012 at Médica Sur Clinic and Foundation ICU. MATERIAL AND METHODS: We performed a five years retrospective study including every cirrhotic patient admitted to ICU between January 2007 and December 2012. RESULTS: The incidence of hemorrhage was 48.5%, the overall incidence of thrombotic complications was 13.66%. Variceal bleeding was the most prevalent hemorrhagic event and portal vein thrombosis the most common thrombotic event. Factors associated with presenting a bleeding episode included kidney injury, infection an thrombosis. Factors associated with increased thrombotic risk included ascitis,infection and bleeding. CONCLUSION: Critically ill cirrhotic patients have an high risk for both thrombotic and bleeding episodes. The association between the presence of bleeding and thrombotic events was statistically significant.

[Elena de Cespedes: The eventful life of a XVI century surgeon]. / Elena de Céspedes. La azarosa vida de una cirujana del siglo XVI.

Throughout the history of surgery there have been exceptional cases of surgeons around the world. One of them is Elena/o of Cespedes. Born as a girl, this hermaphrodite dedicated all his life to acting as a man, doing jobs that were only for men such as a soldier, peasant, and surgeon. She was the first licensed surgeon in Spain and maybe in all Europe. She married a woman and then was tried for sodomy by the Spanish Inquisition commanded by inquisitor Lope de Mendoza. She was founded guilty and punished with 200 lashes and a 10-year service at a hospital, dressed as a woman.

[Andres Vesalio, Francisco Díaz, Miguel de Cervantes Saavedra and the birth of urology in the 16th Century]. / Andrés Vesalio, Francisco Díaz, Miguel de Cervantes Saavedra y el nacimiento de la urología en el siglo XVI.

In the sixteenth century there were great advances in science, literature, and the arts. During this century, urology as a specialty was conceived, thanks to the contributions of Andreas Vesalius, anatomist and leading physician to the court of Charles V, and Dr. Francisco Diaz, a native of Alcala de Henares, surgeon and clinician. Dr. Diaz had a close relationship with Miguel de Cervantes, who at one point in his life suffered from renal colic. In his masterpiece "Re-Printed Treaty of all diseases of the kidneys, bladder and wattles of the Cock and Urina, divided into three books," of which the first book of urology is the History of Medicine, describes in detail the clinical and therapeutic aspects of urological diseases, known as the "bad stone" and urethral strictures known as "wattles", in addition to describing the different surgical techniques and the development of new instruments for urological procedures, which include the cisorio instrument and the Speculum pudendi. For the above, Dr. Francisco Diaz is considered the father of urology.

[Ultrasonographic evaluation of the diameter of the optic nerve sheath for medication of intracranial pressure: a case report]. / Evaluación ultrasonográfica del diámetro de la vaina del nervio óptico (DVNO) para la medición de la presión intracraneana (PIC): a propósito de un caso.

The main complication associated with acute brain injury is the elevation of intracranial pressure (ICP) and it is associated with high morbidity and mortality. In these patients, multimodal neurological monitoring has emerged as a fundamental tool in the intensive care unit, with the minimally invasive trend seen in recent years. We report the case of a patient in which ICP monitoring was based on the measurement of the diameter of the optic nerve sheath (DONS), a procedure that has shown a good correlation with the ICP, as well as a high specificity, sensitivity, and low cost.

Coagulation abnormalities in the cirrhotic patient.

The clotting process is a dynamic array of multiple processes which can be described in four phases: platelet plug initiation and formation, clotting process propagation by the coagulation cascade, clotting termination by antithrombotic mechanisms and clot removal by fibrinolysis. The liver plays a central role in each of these phases of clotting process, as it synthesizes the majority of coagulation factors and proteins involved in fibrinolysis as well as thrombopoeitin, which is responsible for platelet production from megakaryocytes. Many pathological processes associated with cirrhosis, such as portal hypertension and endothelial dysfunction, as well as co-morbid conditions, may also alter the coagulation process. Consequently, patients with liver disease have a disturbed balance of procoagulant and anti-coagulant factors which deviates from the normal coagulation cascade. This situation poses an additional problem in the diagnostic and therapeutic approach to this group of patients, since traditional coagulation test may not be reliable for assessing bleeding or thrombotic risk and traditional transfusional strategies may not be applicable in cirrhotic patients. In this article, we review the pathophysiological bases of coagulation abnormalities, in cirrhotic patients, the diagnostic therapeutic strategies to be followed and its impact on the clinical outcome in the cirrhotic patient.

Rhombencephalitis by Listeria monocytogenes in a cirrhotic patient: a case report and literature review.

We report a case of rhombencephalitis infection by Listeria monocytogenes in a 66-year-old man with cirrhosis. The CSF analysis indicated L. monocytogenes as the most likely pathogen. Blood and CSF culture were positive to L. monocytogenes and MRI findings were suggestive of rhomboencephalitis. The treatment was started empirically and then modified when the culture results were available. The patient had a full clinical recovery without neurologic sequelae. Clinicians should remember that L. monocytogenes most often presents as acute bacterial meningitis, particularly in the elderly, the immunosuppressed, and those with malignancies. L. monocytogenes CNS the infections may present as acute bacterial meningitis, meningoencephalitis, or acute encephalitis.

[Liver abscess syndrome with lung involvement secondary to hypermucoviscosity Klebsiella pneumoniae]. / Síndrome de absceso hepático secundario a Klebsiella pneumoniae hipermucoviscosa con involucro pulmonar.

Klebsiella pneumoniae liver abscess syndrome (KLAS) is an emerging infection characterized by primary monomicrobial liver abscess, bacteremia and metastatic complications. KLAS is endemic in Taiwan but additional cases has also been described in other world regions. It's caused by strains of K. pneumonia serotype K1, rmpA, magA positive, displaying hypermucoviscosity. We present the case of a previously healthy 69 years old patient who developed fever, liver abscess,septic shock, bacteremia, and pneumonia. In cultures grew hypermucoviscous phenotype of K. pneumonia characterized by positive "string test". The patient responded favourably to antibiotic therapy with ceftriaxone, meropenem, amykacin and percutaneous drainage of the abscess. Increased awareness about this globally emerging infection by physicians could allow earlier detection and optimal treatment.

Impact of Hospital-based Multidisciplinary Anticoagulation Stewardship Programs.

Antithrombotic therapies, especially anticoagulants, are high-risk medications with increased potential for adverse events. The development and implementation of a well-functioning, designated, multidisciplinary anticoagulation stewardship program (MASP), tailored to each hospital-center's needs, has the primary objectives of improving patient-centered outcomes, minimizing undesirable anticoagulation-related adverse events and minimizing hospital length of stay (LOS) and other patient-related costs. Such stewardship programs are pivotal in supporting busy clinicians with consultation on challenging clinical case scenarios, ensuring appropriate use of valuable healthcare resources, achieving compliance with anticoagulant-associated accreditation standards, and positively impacting patient-specific morbidity/mortality outcomes. Herein, we review and discuss the critical need for antithrombosis stewardship and the benefit of formalized MASP in optimizing use of antithrombotic therapies.

Patient Blood Management in Liver Transplant-A Concise Review.

Transfusion of blood products in orthotopic liver transplantation (OLT) significantly increases post-transplant morbidity and mortality and is associated with reduced graft survival. Based on these results, an active effort to prevent and minimize blood transfusion is required. Patient blood management is a revolutionary approach defined as a patient-centered, systematic, evidence-based approach to improve patient outcomes by managing and preserving a patient's own blood while promoting patient safety and empowerment. This approach is based on three pillars of treatment: (1) detecting and correcting anemia and thrombocytopenia, (2) minimizing iatrogenic blood loss, detecting, and correcting coagulopathy, and (3) harnessing and increasing anemia tolerance. This review emphasizes the importance of the three-pillar nine-field matrix of patient blood management to improve patient outcomes in liver transplant recipients.

Acute kidney injury in critically ill cirrhotic patients: a review.

Acute kidney injury (AKI) is an important marker of morbidity and mortality in critically ill cirrhotic patients. The most common causes of AKI in cirrhotic patients include prerenal or hepatorenal syndrome (HRS). Diagnosis of AKI may be delayed by the lack of clinical, biochemical, and radiological markers with proven sensitivity and specificity in cirrhotic patients. In this review, we discuss the epidemiology, pathophysiology, diagnosis, and therapies for AKI in cirrhotic patients admitted to an intensive care unit (ICU).

The burned patient in times of COVID-19: proposal derived from lessons learned.

COVID-19 is a public health problem, so any burn patient who is managed as an outpatient or requires hospital management is a potential carrier of SARS-CoV-2. Burn patients are susceptible to COVID-19 due to the burn and its immunosuppressive effect, the procedures they undergo and other factors related to the burn, which makes them at high risk of contracting the disease and transmitting it, especially to the healthcare team involved in its management. Therefore, it is important to organize strategies in the services that care for burn patients during the COVID-19 pandemic. The objective of this paper is to present a proposal for response, organizational management and strategic planning in a burns service in times of COVID-19, based on the lessons and experience acquired.

La COVID-19 es un problema de salud pública, por lo que cualquier paciente quemado que se maneje como externo o que requiera manejo hospitalario es un potencial portador del SARS-CoV-2. El paciente quemado es susceptible a la COVID-19 debido a la quemadura y a su efecto inmunodepresor, a los procedimientos a los que es sometido y a otros factores inherentes a la quemadura, lo que le hace un paciente con alto riesgo de contraer la enfermedad y trasmitirla, especialmente al equipo de salud que está involucrado en su manejo. Por lo anterior, es importante organizar estrategias en los servicios que atienden pacientes con quemaduras durante la pandemia de COVID-19. El objetivo de este trabajo es presentar una propuesta para la respuesta, el manejo organizativo y la planeación estratégica en un servicio de quemados en tiempos de COVID-19, basándonos en las lecciones aprendidas y la experiencia adquirida.

Ultrasound meal accommodation test in critically ill patients with and without feeding intolerance UMAT-ICU.

BACKGROUND: Gastrointestinal dysfunction (GID) is one of the leading causes of nonavoidable discontinuing or delayed enteral feeding in critically ill patients. The ultrasound meal accommodation test (UMAT) has been used in ambulatory patients to evaluate dyspepsia. The objective of this study was to determine differences in the UMAT scores of critically ill patients with and without feeding intolerance (FI). METHODS: A prospective, observational, two-centre study was conducted between June and August 2019. We included subjects who met the criteria for enteral nutrition. Patients and their subrogates provided signed consent for intervention. The independent variables were cross-sectional area (CSA) and calculated gastric volume (CGV). Dependent variables were changes in the UMAT at Time 1 and Time 2 and gastric residue in those with and without FI. After that, patients were divided into two groups, depending on the development of GID over the following 48 h after inclusion in the study group A, subjects without FI; and group B, subjects with FI. According to the normal distribution in parametric or non-parametric tests. Differences between groups were determined using a Student's T-test. A p-value of ≤0.05 was established for the statistical difference between groups. At 60 min, a change cut-off point of 52% has a sensitivity of 50%, specificity of 88.9%, a positive likelihood ratio of 4.50 and a negative likelihood ratio of 0.56. With a pretest probability of 85% for feeding tolerance in intensive care unit patients, the posttest probability increased to 96% with a positive test with the ΔCSA. RESULTS: 61 patients were included in the study; 52 (85%) in Group A and 9 (15%) in Group B. However, at time 0 (fasting), there were statistical differences in CSA and CGV between groups (p = 0.001). During Time 1 (dynamic changes), there were statistical differences between the groups (p = 0.008 for CSA and p = 0.011 for CGV). At time 3 (Delta), there were statistical differences between groups at minute 10 (p = 0.023 for CSA and p = 0.008 for CGV). CONCLUSION: Our study showed statistical differences in the UMAT test between patients with and without FI. TRIAL REGISTRATION: Clinical trials registry NCT03851354. February 22, 2019.