Serum zinc levels in hemodialysis and peritoneal dialysis patients: A retrospective observational study.

Background: Zinc is vital for cellular functions, but kidney failure increases zinc deficiency risk. We compared zinc levels in hemodialysis (HD) and peritoneal dialysis (PD) patients in Isfahan, Iran. Materials and Methods: A retrospective study included 150 patients (75 PD and 75 HD). Serum zinc levels were assessed through photometry. Statistical analysis employed Chi-square, independent t-test, and correlation. Results: Serum zinc was below normal in both groups (P < 0.01). HD patients had lower zinc levels (70.85 ± 7.68 mg/dL) compared to PD (75.04 ± 13.55 mg/dL, P = 0.021), remaining significant after adjusting for confounders (P = 0.011). Conclusion: Zinc levels in PD and HD patients are lower than in the general population, with HD patients having lower levels than PD patients.

Animal protein intake is directly associated with serum level of pentraxin 3 in hemodialysis patients.

Inflammation plays an important role in Cardiovascular disease (CVD) pathogenesis as the main cause of mortality in hemodialysis (HD) patients. Despite the relevance of nutrition and dietary intakes for inflammation status, the role of dietary protein sources remains unclear. The aim of this study was to evaluate the association between the different types of dietary protein and pentraxin 3 (PTX3) levels in HD patients. In this multi-center cross-sectional study, 227 adult patients undergoing HD for a minimum 90 days were recruited. A validated 168-item food frequency questionnaire was used to assess dietary intakes. Also, 5 ml blood samples were collected from each patient to measure the concentration of serum PTX3. Overall, 227 patients, including 63 women and 164 men, with a mean age of 58 years, participated in this study. There was a greater intake of animal protein per kilogram dry weight among patients with higher levels of PTX3 (0.46 vs. 0.54 g/kg; P = 0.035). In contrast, consumption of total protein and plant protein per kilogram dry weight was not different across PTX3 levels. Moreover, the chance of increased PTX3 concentration was directly associated with a one-unit increase in animal protein intake per kilogram dry weight, after adjusting for confounders. We did not observe any association between one-unit increases in plant protein intake per kilogram dry weight and chance of increased PTX3. In conclusion, animal protein intake was directly associated with circulating PTX3.

The effects of oral sodium bicarbonate supplementation on anthropometric measures in patients with chronic kidney disease: A systematic review and meta-analysis of randomized clinical trials.

Metabolic acidosis (MA) may play a key role in the pathogenesis of protein-energy wasting (PEW) in patients with chronic kidney disease (CKD). To present a comprehensive synthesis of the effect of oral sodium bicarbonate (SB) supplementation on anthropometric measures in patients with CKD, a systematic review was undertaken in PubMed/MEDLINE, Web of Science, Cochrane CENTRAL, and Google Scholar, of relevant articles published prior to September 2022. The summary statistics of effect size, nonstandardized weighted mean difference (WMD), and 95% confidence interval (CI) were used to compare the effects of SB supplementation on anthropometric parameters vs. control group. To detect probable sources of heterogeneity, a series of predefined subgroup analyses were conducted. In total, 17 studies with 21 treatment arms, including 2203 participants (1149 cases, 1054 controls), met our inclusion criteria and were included in the meta-analysis. SB supplementation had no significant effect on body weight (BW), midarm muscle circumference (MAMC), or lean body mass (LBM) in patients with CKD. There was a significant increase in body mass index (BMI) (MD: 0.59 kg/m2, 95% CI: 0.25 to 0.93, p = 0.001) after SB supplementation in the overall analysis. In subgroup analysis, LBM was increased in studies that were ≥ 24-week duration (MD: 1.81 kg, 95% CI: 0.81 to 2.81) and in participants with BMI lower than 27 kg/m2 (MD: 1.81 mg/L, 95% CI: 0.81 to 2.81). SB supplementation may yield increases in BMI in predialysis CKD patients. However, our findings did not support the beneficial effects of SB supplementation on other anthropometric outcomes. There is an evident need for long-term high-quality interventions to confirm these findings.

Metabolic health status and renal disorders: a cross-sectional study.

Previous surveys suggests that body mass index (BMI) may be positively related to development of chronic kidney disease (CKD). However, this association might be altered by metabolic syndrome. Therefore, we aimed to evaluate the association of metabolic health status with CKD. The present cross-sectional study was carried out on 3322 representative sample of Iranian adults. Metabolic syndrome was identified based on the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) and BMI was assessed by anthropometric measurements. Estimated glomerular filtration rate (eGFR) was calculated by modification of diet in renal disease-Chronic Kidney Disease Epidemiology Collaboration (MDRD-EPI) formula. Subjects were categorized into four phenotypes: metabolically healthy normal weight (MHNW), metabolically healthy overweight and obesity (MHO), metabolically unhealthy normal weight (MUHNW), and metabolically unhealthy overweight and obesity (MUHO). Based on multivariate-adjusted models, the risk of CKD was significantly higher in MUHO compared with MHNW (OR: 1.48; p < 0.05). Although MUHNW and MUHO were associated with lower eGFR and albuminuria, the significant association was not observed in case of hematuria. Furthermore, subjects with kidney stones tended to be in MHO (OR: 1.42; p < 0.05) and MUHO phenotypes (OR: 1.64; p < 0.05), in comparison to the MHNW phenotype. The odds of kidney disorders were higher in adults with metabolic syndrome, regardless of BMI. However, this relationship might be strengthened by the concomitance of metabolic syndrome and obesity. To verify our findings, clarify the causality, and elucidate the underlying mechanisms, further research are warranted.

Anti-GBM disease with positive serum anti-GBM antibodies but negative IgG deposition: A case report.

Anti-glomerular basement membrane antibodies are significantly specific for detecting anti-glomerular basement membrane disease. These antibodies are typically targeted against the non-collagenous (NC1) domain of the alpha 3 chain of type IV collagen and, to a lesser extent, the α4(IV) or α5(IV) chains, which create a triple-helical structure in the glomerular basement membrane. The modification of the hexameric structure of NC1 (α3(IV)) results in the exposure of new epitopes, leading to an immune reaction and the subsequent deposition of linear antibodies along the glomerular basement membrane, culminating in crescentic glomerulonephritis. Anti-glomerular basement membrane antibodies that are positive are believed to be pathogenic and capable of binding to the glomerular basement membrane in vivo, particularly in the context of rapidly progressive glomerulonephritis. Herein, we present a patient with positive serum anti-glomerular basement membrane antibodies but negative IgG deposition. The current findings are significant for raising physicians' awareness of the probable errors in detecting anti-glomerular basement membrane antibody disease as a possible cause of irreversible kidney failure.

Assessing physical inactivity as a risk factor for chronic kidney diseases in Iranian population.

OBJECTIVES: Physical inactivity is a major adjustable lifestyle risk factor in renal patients; nevertheless, research on the association of physical activity (PA) with chronic kidney disease (CKD) is unclear. DESIGN: Cross-sectional. SETTING: We evaluated the secondary care related to the nephrology specialists. PARTICIPANTS: We evaluated PA in 3374 Iranian patients with CKD aged ≥18 years. Exclusion criteria were current or prior kidney transplantation, dementia, institutionalisation, expected to start renal replacement therapy or leave the area within study duration, participation in a clinical trial or inability to undergo the informed consent process. PRIMARY AND SECONDARY OUTCOME: The renal function parameters were measured and compared with PA, assessed by the Baecke questionnaire. Estimated glomerular filtration rate, haematuria and/or albuminuria were used to estimate decreased kidney function and the incidence of CKD. To estimate the relationship between PA and CKD, we used the multinomial adjusted regression models. RESULTS: In the first model, findings indicate that the patients with the lowest PA score had significantly higher odds of CKD (OR 1.44, 95% CI 1.16 to 1.78; p=0.01), adjustment for age and sex attenuated this relationship (OR 1.25, 95% CI 1.56 to 1.78, p=0.04). Furthermore, adjusting for low-density lipoprotein, high-density lipoprotein, triglyceride, fasting blood glucose, body mass index, waist circumference, waist/hip ratio, coexisting diseases and smoking made this relationship insignificant (OR 1.23, 95% CI 0.97 to 1.55; p=0.076). After adjusting for potential confounders, we found that patients with lower PA have higher odds of CKD stage 2 (OR 1.62, 95% CI 1.13 to 2.32; p=0.008), no association with other CKD stages. CONCLUSION: These data suggest that physical inactivity contributes to the risk of early CKD, so encouraging patients with CKD to maintain higher PA levels could be used as a simple and useful tool to decrease the risk of disease progression and its related burden.

Association of alcohol consumption with the prevalence and various stages of chronic kidney disease.

Background: Considering that the effect of alcohol consumption trend on the prevalence of kidney damage and its progression has not been determined yet, the study aimed at investigating the association between alcohol consumption and the risk of chronic kidney disease (CKD) prevalence and progression at various stages of the disease. Materials and Methods: This cross-sectional study was performed on 3374 participants that referred to health-care centers in Isfahan from 2017 to 2019. Participants' basic and clinical characteristics (such as sex, age, education level, marital status, body mass index, blood pressure, alcohol consumption, comorbidities, and laboratory parameters) were evaluated and recorded. The alcohol consumption trend was classified as never, occasional (<6 drinks/week), and frequent (≥6 drinks/week) based on the amount of alcohol consumption over the last 3 months. Moreover, CKD stages were recorded based on the Kidney Disease: Improving Global Outcomes guideline, as well. Results: In the present study, the occasional and frequent drinking of alcohol did not have a significant effect on the odds of CKD prevalence (odds ratio [OR]: 1.32 and 0.54; P > 0.05) and the odds of stage 2 CKD prevalence as compared to stage 1 CKD prevalence (OR: 0.93 and 0.47; P > 0.05). However, adjusting the confounding factors revealed that occasional drinking as compared to nondrinking increased the odds of stage 3 and 4 CKD prevalence as compared to stage 1 CKD prevalence by 3.35 folds, respectively (P < 0.05). Conclusion: According to the results of this study, occasional drinking as compared to nondrinking significantly increased the odds of stage 3 and 4 CKD prevalence as compared to stage 1 CKD prevalence.

Is Chronic Kidney Disease, a Predictor of In-Hospital Mortality in Coronavirus Disease 2019 (COVID-19) Patients?

Background: Chronic kidney disease (CKD) is an important comorbidity in Coronavirus Disease 2019 (COVID-19) patients considering its high prevalence. We aimed to figure out the relationship between CKD and COVID-19 mortality in this study. Materials and Methods: In total, 116 CKD patients (estimated glomerular filtration rate [eGFR] lower than 60 mL/min/1.73 m2) and 147 control subjects confirmed with COVID-19 were studied. Data regarding demographics, sign and symptoms, laboratory findings, and chest computed tomography were collected. Association between CKD and in-hospital mortality were analyzed using logistic regression models adjusted for confounders. Results: Mortality rate was significantly higher in CKD than non-CKD (30.17 vs 4.76, P < 0.001) COVID-19 patients. Multivariate logistic regression showed that CKD was significantly correlated with in-hospital mortality in the total sample (Odds ratio (OR) = 8.64, confidence interval (CI): 3.67-20.35) and gender subgroups (females: OR = 4.77, CI: 1.38-16.40, males: OR = 13.43, CI: 3.85-46.87) (P < 0.05) of COVID-19 patients in the crude model. Whereas, the correlation did not remain significant in the fully adjusted model in the total sample (OR = 1.70, CI: 0.35-8.19) and gender subgroups (females: OR = 1.07 CI: 0.06-19.82, males: OR = 0.87, CI: 0.07-10.33) (P > 0.05) of COVID-19 patients. Conclusion: This study suggested an independent association between CKD and in-hospital mortality in COVID-19 patients. Therefore, more intensive surveillance of COVID-19 patients with CKD is to be warranted.

The effect of linagliptin on microalbuminuria in patients with diabetic nephropathy: a randomized, double blinded clinical trial.

The aim of the present study was to investigate the effect of linagliptin on microalbuminuria in patients with diabetic nephropathy (DN). The present double-blind randomized placebo-controlled clinical trial was performed on 92 patients with DN who were divided into two groups. The intervention and control groups received linagliptin 5 mg and placebo for 24 weeks, respectively. Blood pressure, lipid profile, liver enzymes, fasting plasma glucose (FPG), and urine albumin-creatinine ratio (UACR) were assessed and recorded before, 12 weeks, and 24 weeks after the beginning of the intervention. The mean value of UACR decrease was significant over time in both groups, with higher decrease in linagliptin group, however, the differences between two groups were not, statistically significant (P > 0.05). However, the percentage of improvement in microalbuminuria (UACR < 30 mg/g) in the linagliptin group was significantly higher than that of the control group during 24 weeks of intervention (68.3% vs. 25%; P-value < 0.001). There was no statistically significant difference in the mean value of the UACR and other parameters between linagliptin treated and placebo treated patients with diabetic nephropathy. Further studies, with longer periods of follow-up are suggested to examine these patients' renal outcomes.

Bilateral peripheric facial nerve palsy following SARS-CoV-2 infection: A case report and review of literature.

Neurologic complications of SARS-CoV-2 infection have been reported commonly. Peripheric facial nerve palsy is one of the most reported neurologic problems. However, idiopathic bilateral facial palsy is a very rare complication of SARS-CoV-2 infection. Herein, we present a case of a COVID-19 35-year-old man, which developed bilateral facial palsy.

Chronic Kidney Disease in Isfahan Province, Action Plan for Screening in A Population-based Study.

INTRODUCTION: We intended to explore the prevalence of chronic kidney disease (CKD) and its different stages, as well as CKD associated variables in the adult population in Isfahan province, Iran. METHODS: Adults aged ≥ 18 were recruited in a cross-sectional study from 2017 to 2019. Data including demographics, anthropometrics, and laboratory findings were collected from each subject. The equation of chronic kidney disease- Epidemiology Collaboration (CKD-EPI) was used to estimate glomerular filtration rate (eGFR), and eGFR and UACR values were utilized to determine the stages of CKD. RESULTS: Data from a total of 3374 subjects was analyzed. The mean age of participants was 49.3 ± 14.09 years and 59.3% were female. The prevalence of CKD was 18.5%. Only 0.25 and 3.5% of the population were in CKD stage 3 and 4, while most of the patients were in CKD stage 2 (7.6%) and stage 1 (7.1%). CKD patients were mostly on refined grains diet and used lesser dairy products compared to healthy participants. Variables including systolic blood pressure (OR = 1.018; P < .001), diastolic blood pressure (OR = 1.005; P < .05), fasting blood sugar (OR = 1.011; P < .001), female sex (OR = 1.319; P < .05), body mass index (OR = 1.030; P < .05), married status (OR = 1.335; P < .05), and smoking (OR = 1.529; P < .05) were significantly associated with increased risk of CKD in the logistic regression analysis. CONCLUSION: According to our results, the prevalence of CKD, especially stages 1 and 2, is quite high in central part of Iran. These findings help us to improve the screening for CKD patients and perform larger scale studies to identify the challenges ahead.  DOI: 10.52547/ijkd.7201.

Association between nutritional, inflammatory and oxidative status (NIOS) and risk of adverse outcomes in patients on haemodialysis (HD): the NIOS-HD prospective cohort study protocol.

INTRODUCTION: The mortality of patients on chronic haemodialysis is 10-30 times greater than that of the general population and over 60% of these individuals die within the first 5 years of beginning haemodialysis. Although causes for excessive mortality in haemodialysis patients are not clearly defined, it seems that nutrition, inflammation and oxidative stress play key roles in this regard. Until now, no cohort study has focused on the association between nutritional, inflammatory or oxidative status and risk of complications and adverse outcomes in Iranian haemodialysis patients. Therefore, we sought to fill this gap and designed the Nutritional, Inflammatory, and Oxidative Status in Hemodialysis (NIOS-HD) prospective cohort study to determine the association of dietary factors, malnutrition, anthropometric indices, body composition, inflammation and oxidative stress with quality of life, dialysis access infections, hospitalisation, potential years of life lost and mortality in adults on maintenance haemodialysis in Isfahan, Iran. METHODS AND ANALYSIS: The sample size of this cohort was estimated to be 300 participants. At baseline, demographic, medical and dialysis-related data of eligible patients will be recorded. In addition, participants will undergo anthropometric measurements, malnutrition assessment and body composition analysis. Also, their dietary intake and quality of life will be evaluated through interviewer-administered questionnaires. Moreover, their fasting blood samples will be collected and stored for biochemical assays including transthyretin, albumin, serum amyloid A, pentraxin-3, trimethylamine N-oxide, myeloperoxidase, paraoxonase-1 and superoxide dismutase. After baseline evaluation, patients will be followed up to 3 years to update exposure information (except biochemical assays) and measure adverse outcomes. Finally, collected data will be analysed using descriptive and inferential statistics. ETHICS AND DISSEMINATION: The NIOS-HD is in agreement with the Declaration of Helsinki and has been approved by the Ethics Committee of Isfahan University of Medical Sciences (reference number: IR.MUI. RESEARCH: REC.1399.605). Findings of this study will be published in academic journals.

Parsonage-Turner Syndrome following COVID-19 Infection: A Rare and Unique Case.

Parsonage-Turner syndrome (PTS) is a rare syndrome of unknown etiology; however, it is believed that an abnormality of immune response after a previous infection may be the cause of the disease. We report neuralgic amyotrophy in a patient with a history of kidney transplantation with severe acute respiratory distress syndrome coronavirus 2 infection. This literature is reviewed regarding clinical presentation, etiology, treatment, and prognosis of PTS after COVID-19 infection. We should consider PTS as another complication of COVID-19 infection.

Pruritus-reducing effects of omega-3 fatty acids in hemodialysis patients: A cross-over randomized clinical trial.

INTRODUCTION: Chronic kidney disease-associated pruritus is a common complication in patients with end-stage renal disease. In this study, we have explored the outcome of omega-3 supplementary intake for the treatment of this symptom. METHODS: This double-blinded, randomized, crossover study was conducted in two dialysis centers in which 40 hemodialysis patients suffering from pruritus were randomly assigned into two groups (Group A and Group B). Patients in Group A consumed omega-3 capsules for 4 weeks and after a washout period (6 weeks), they took placebo for another 4 weeks. The same was performed in Group B but in the reverse order. Pruritus score was determined at the baseline, Week 4, 10, and 14. Serum levels of prostaglandin E2 were also recorded at the baseline and Week 4. RESULTS: There was a statistically significant reduction of pruritus score in patients who took the omega-3 fatty acid supplement. The mean pruritus score decreased significantly in both first (-3.41 ± 2.62, p < 0.001) and second (-1.00 ± 1.84, p = 0.04) treatment period after omega-3 treatment; but no significant mean pruritus score difference in placebo group after both intervention periods was observed. The decrease in prostaglandin E2 amount was not statistically significant in the intervention (omega-3) group compared to the placebo group (p = 0.204). DISCUSSION: Our observations indicate that omega-3 fatty acids (3 grams per day) have decreasing effects on pruritus. Also, reduction in prostaglandin E2 levels in the omega-3 group did not differ from the changes in the placebo group.

Chronic Kidney Disease and COVID-19 Infection: A Case-Control Study.

Background: To organize efforts to manage the coronavirus disease 2019 (COVID-19), it is necessary to understand which groups are at higher risk of infection. Kidney disease seems to be substantial in COVID-19 patients, but there are limited data on COVID-19 incidence and fatality among chronic kidney disease (CKD) patients. In this study, we intend to examine the association between CKD and susceptibility to COVID-19 infection. Materials and Methods: Participants were selected from those recruited in a population-based cross-sectional survey of CKD prevalence and associated risk factors in Iranian people 18 years and older. A three-part questionnaire was used for COVID-19 infection clinical symptoms and epidemiologic and hospitalization data. Results: A total of 962 individuals including 403 CKD patients and 559 healthy controls were recruited in this study. Healthy controls were suffering more from common cold signs, cough, fever, sore throat, headache, anosmia, dyspnea, and abdominal pain (all P < 0.05). Furthermore, the number of healthy individuals with myalgia was marginally higher compared to the CKD patients (P = 0.057). Data regarding the number of CKD patients with/without COVID-19 infection throughout different CKD stages revealed that there was no significant difference between the two groups in terms of COVID-19 infection in different stages of CKD (P = 0.956). Conclusion: We found that some of the clinical presentations of COVID-19 including common cold symptoms, cough, fever, sore throat, headache, anosmia, dyspnea, and abdominal pain were higher among healthy individuals compared to the CKD group. On the other hand, the susceptibility to COVID-19 infection was not significantly different in various early stages of CKD.

Evaluating the effect of intradialytic cycling exercise on quality of life and recovery time in hemodialysis patients: A randomized clinical trial.

Background: The aim of this study was to assess the effect of intradialytic cycling exercise on quality of life (QOL) and recovery time in patients who underwent hemodialysis. Materials and Methods: Hemodialysis patients were recruited from the referral dialysis centers affiliated with Isfahan University of Medical Sciences, Isfahan, Iran. Patients were randomly assigned into the intervention and the control groups. Patients in the intervention group exercised on a stationary bike for 12 weeks (3 times per week for 30 min); however, patients in the control group received usual hemodialysis. The kidney disease QOL (KDQOL)-short-form version 1.3 was used to assess QOL. Patients were asked to answer the question "How long does it take to recover from a dialysis session?" to assess recovery time. Results: A total of 110 hemodialysis patients, including 60 in the intervention group and 50 in the control group were analyzed. A significant increase was observed in the generic (mean difference ± SE: 1.50 ± 0.44, P = 0.001), kidney disease (mean difference ± SE: 0.84 ± 0.28, P = 0.004), and overall QOL (mean difference ± SE: 1.18 ± 0.33, P = 0.001) scores after 12 weeks of intradialytic cycling exercise in the intervention group. Furthermore, a significant difference was noted between the intervention and the control group regarding the mean difference of all QOL scores after the intervention (P < 0.05). We also found a significant difference in the mean difference of recovery time between the intervention and the control group after the intervention (P < 0.001). Conclusion: KDQOL and recovery time could improve in hemodialysis patients after 12-week intradialytic exercise.

Hemoperfusion in patients with severe COVID-19 respiratory failure, lifesaving or not?

BACKGROUND: The new coronavirus outbreak quickly filled hospital beds and stunned the world. Intensive care is required for 5% of patients, and the mortality rate for critically ill patients is 49%. The "cytokine storm" is considered as the main cause of pathogenesis for coronavirus disease-19 (COVID-19)-related respiratory failure, hemoperfusion may be a modality for treatment of disease. MATERIALS AND METHODS: Thirty-seven an patients with positive real-time polymerase chain reaction for SARStions2 in an upper respiratory tract sample or typical chest computed tomography lesion were eligible for this case-control study. Patients meeting the criteria for hemoperfusion including clinical and laboratory indices, were evaluated for outcomes such as hospitalization length and mortality. Patients were divided into three groups, i.e., patients who received hemoperfusion without a need for mechanical ventilation (MV), patients who received hemoperfusion before MV, and patients who received hemoperfusion after MV. RESULTS: Among 37 patients with COVID-19 respiratory failure, 32% were female with a mean age of 55.54 (standard deviation 14.1) years. There was no statistically significant difference between the three groups in terms of length of hospital stay and intensive care unit (ICU) stay (P-tayns: 0.593 and 0.243, respectively, confidence interval [CI]: 95%). Heart rate, respiratory rate, PaO2/FIO2, high-sensitivity C-reactive protein, and ferritin significantly improved after the application of hemoperfusion in all groups (P < 0.05, CI: 95%). CONCLUSION: It seems that applying hemoperfusion in the inflammatory phase of the disease, especially before the intubation, reduce the need for MV. However, hemoperfusion does not have any impacts on the duration of hospital and ICU stay.

Designing, implementation, and evaluation of internship comprehensive system for assessment and monitoring.

BACKGROUND: During the past decade, the benefits of using portfolios, especially electronic portfolios, were recognized. Due to the lack of using portfolios and especially electronic portfolio in the clinical evaluations of internship training in medical schools of Iran, this study has designed, implemented, and evaluated a comprehensive system for monitoring and evaluating the activities of interns. MATERIALS AND METHODS: This study was a software development study in the three phases of design, implementation, and evaluation. All stages of the project were carried out in the Isfahan University of Medical Sciences during 2019-2020. The software design phase was performed using the Rapid Application Development Methodology (RAD model). In the implementation phase, it was used as a pilot study in the internal department of the medical school. System evaluation was performed using a combination of quantitative and qualitative methods. Data were analyzed using the content analysis for qualitative data and descriptive statistical analysis using the SPSS software for quantitative data. RESULTS: In the educational standards survey, in 10 items, the percentage of choosing "perfectly fit" and "fit" was above 90% (high quality). In the technical standards questionnaire, out of 35 items related to software technical quality, eight items were of acceptable quality and 27 of them were partially acceptable. In the Student Satisfaction Questionnaire, in 9 items, interns' satisfaction with the system was high or very high, and in either case, there was little or no dissatisfaction or satisfaction. CONCLUSIONS: Positive educational effects can be used in all clinical settings if modification and improvement of the software continues, with slight modifications.