El rol de los suplementos vitamínicos en pacientes con depresión / The role of vitamin supplements in patients with depression

La depresión es un trastorno del estado de ánimo que se caracteriza por la existencia de un sentimiento de tristeza lo suficientemente intenso como para interferir en el desarrollo de las actividades habituales. A partir de un caso clínico real, en el que una paciente con depresión solicita a su médico de cabecera sumar un suplemento de vitaminas a su plan terapéutico, revisamos la evidencia disponible sobre el uso de estos micronutrientes para el tratamiento de la depresión, y encontramos que no existen pruebas robustas que avalen la suplementación vitamínica en pacientes con este problema de salud. (AU)

Depression is a mood disorder characterised by the existence of a feeling of sadness intense enough to interfere with the performance of normal activities. Based on a real clinical case, in which a patient with depression asked her family doctor to add a vitamin supplement to her therapeutic plan, we reviewed the available evidence on the use of these micronutrients for the treatment of depression and found that there is no robust evidence to support vitamin supplementation in patients with this health problem. (AU)

Beneficios de la evaluación integral en adultos mayores con dolores crónicos de columna en un centro periférico del conurbano bonaerense / Benefits of the comprehensive evaluation in older adults with chronic back pain, in a peripheral medical center of the Buenos Aires suburbs

Introducción. Desde hace varios años, el abordaje de los pacientes adultos mayores que consultan por dolor crónico en un centro periférico del Hospital Italiano del conurbano bonaerense se realiza de manera integral, mediante la evaluación conjunta de una kinesióloga y un médico de familia, lo que facilita la indicación terapéutica individualizada, con la aplicación de estrategias cognitivo-conductuales. Objetivo. Documentar los resultados clínicos luego de una evaluación integral de pacientes mayores de 60 años que consultaron por dolor crónico de columna refractarios a tratamientos monodisciplinarios. Métodos. Estudio observacional, analítico tipo antes-después, prospectivo. Recolectamos variables descriptivas de los participantes al momento de la evaluación integral (demográficas, antropométricas, contextuales y clínicas) y de desenlace: dolor, calidad de vida y actividad física a los tres y seis meses, consultas no programadas y a servicio de traumatología durante ese periodo. Estimamos necesaria una muestra de 30 pacientes, pero debido a la pandemia por SARS-CoV-2finalizamos precozmente el estudio con los pacientes reclutados hasta ese momento. Resultados. Incluimos nueve participantes (edad media 66,5 años, desviación estándar 4,9; 67 % sexo femenino). Todos completaron el seguimiento a seis meses. Observamos reducción del dolor y mejoría de la calidad de vida a los seis meses (cambio en la escala visual analógica [EVA] -3, intervalo de confianza [IC] 95 % -5,1 a -0,94; cambio en el puntaje del EQ-5D-3L 0,17, IC 95 % 0,08 a 0,26, respectivamente). Conclusión. En los pacientes adultos mayores de 60 años con dolor crónico de columna no oncológico evaluados de manera integral por un médico de familia y un kinesiólogo se observó una mejoría del dolor y la calidad de vida a los seis meses de seguimiento. Debido a que el diseño no incluyó un grupo control estas diferencias no pueden atribuirse de manera fehaciente a la intervención, aunque estos hallazgos son concordantes con los de ensayos previos. (AU)

Introduction. For several years, the approach of elderly patients who consult for chronic pain in a peripheral center ofthe Hospital Italiano de Buenos Aires has been carried out in a comprehensive way, through the joint evaluation of akinesiologist and a family doctor, which facilitates individualized therapeutic indication, with the application of cognitive-behavioral strategies.Objective. To document the clinical results after the comprehensive evaluation of patients over 60 years of age whoconsulted for chronic back pain refractory to monodisciplinary treatments. Methods. Observational, analytical, before-after, prospective study. We collected descriptive variables from the participantsat the time of the comprehensive evaluation (demographic, anthropometric, contextual and clinical) and outcome variables:pain, quality of life and physical activity at three and six months, unscheduled consultations and trauma service during thatperiod. We estimate that a sample of 30 patients is necessary, but due to the SARS-CoV-2 pandemic we ended the studyearly with the patients recruited up to that time. Results. We included nine participants (mean age 66.5 years, standard deviation 4.9; 67 % female). All completed the six-month follow-up. We observed reduction in pain and improvement in quality of life at six months (change in visual analogscale [VAS] -3, 95 % confidence interval [CI] -5.1 to -0.94; change in score of the EQ-5D-3L 0.17, 95 % CI 0.08 to 0.26,respectively). Conclusion. In adult patients over 60 years of age with chronic non-cancer back pain who were comprehensively evaluatedby a family doctor and a kinesiologist, an improvement in pain and quality of life was observed at six months of follow-up. Since the design did not include a control group, these differences cannot be reliably attributed to the intervention, althoughthese findings are consistent with those of previous trials. (AU)

Reducing medication errors for adults in hospital settings.

BACKGROUND: Medication errors are preventable events that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional or patient. Medication errors in hospitalised adults may cause harm, additional costs, and even death. OBJECTIVES: To determine the effectiveness of interventions to reduce medication errors in adults in hospital settings. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers on 16 January 2020.  SELECTION CRITERIA: We included randomised controlled trials (RCTs) and interrupted time series (ITS) studies investigating interventions aimed at reducing medication errors in hospitalised adults, compared with usual care or other interventions. Outcome measures included adverse drug events (ADEs), potential ADEs, preventable ADEs, medication errors, mortality, morbidity, length of stay, quality of life and identified/solved discrepancies. We included any hospital setting, such as inpatient care units, outpatient care settings, and accident and emergency departments. DATA COLLECTION AND ANALYSIS: We followed the standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care (EPOC) Group. Where necessary, we extracted and reanalysed ITS study data using piecewise linear regression, corrected for autocorrelation and seasonality, where possible.  MAIN RESULTS: We included 65 studies: 51 RCTs and 14 ITS studies, involving 110,875 participants. About half of trials gave rise to 'some concerns' for risk of bias during the randomisation process and one-third lacked blinding of outcome assessment. Most ITS studies presented low risk of bias. Most studies came from high-income countries or high-resource settings. Medication reconciliation -the process of comparing a patient's medication orders to the medications that the patient has been taking- was the most common type of intervention studied. Electronic prescribing systems, barcoding for correct administering of medications, organisational changes, feedback on medication errors, education of professionals and improved medication dispensing systems were other interventions studied. Medication reconciliation Low-certainty evidence suggests that medication reconciliation (MR) versus no-MR may reduce medication errors (odds ratio [OR] 0.55, 95% confidence interval (CI) 0.17 to 1.74; 3 studies; n=379). Compared to no-MR, MR probably reduces ADEs (OR 0.38, 95%CI 0.18 to 0.80; 3 studies, n=1336 ; moderate-certainty evidence), but has little to no effect on length of stay (mean difference (MD) -0.30 days, 95%CI -1.93 to 1.33 days; 3 studies, n=527) and quality of life (MD -1.51, 95%CI -10.04 to 7.02; 1 study, n=131).  Low-certainty evidence suggests that, compared to MR by other professionals, MR by pharmacists may reduce medication errors (OR 0.21, 95%CI 0.09 to 0.48; 8 studies, n=2648) and may increase ADEs (OR 1.34, 95%CI 0.73 to 2.44; 3 studies, n=2873). Compared to MR by other professionals, MR by pharmacists may have little to no effect on length of stay (MD -0.25, 95%CI -1.05 to 0.56; 6 studies, 3983). Moderate-certainty evidence shows that this intervention probably has little to no effect on mortality during hospitalisation (risk ratio (RR) 0.99, 95%CI 0.57 to 1.7; 2 studies, n=1000), and on readmissions at one month (RR 0.93, 95%CI 0.76 to 1.14; 2 studies, n=997); and low-certainty evidence suggests that the intervention may have little to no effect on quality of life (MD 0.00, 95%CI -14.09 to 14.09; 1 study, n=724).  Low-certainty evidence suggests that database-assisted MR conducted by pharmacists, versus unassisted MR conducted by pharmacists, may reduce potential ADEs (OR 0.26, 95%CI 0.10 to 0.64; 2 studies, n=3326), and may have no effect on length of stay (MD 1.00, 95%CI -0.17 to 2.17; 1 study, n=311).  Low-certainty evidence suggests that MR performed by trained pharmacist technicians, versus pharmacists, may have little to no difference on length of stay (MD -0.30, 95%CI -2.12 to 1.52; 1 study, n=183). However, the CI is compatible with important beneficial and detrimental effects. Low-certainty evidence suggests that MR before admission may increase the identification of discrepancies compared with MR after admission (MD 1.27, 95%CI 0.46 to 2.08; 1 study, n=307). However, the CI is compatible with important beneficial and detrimental effects. Moderate-certainty evidence shows that multimodal interventions probably increase discrepancy resolutions compared to usual care (RR 2.14, 95%CI 1.81 to 2.53; 1 study, n=487). Computerised physician order entry (CPOE)/clinical decision support systems (CDSS) Moderate-certainty evidence shows that CPOE/CDSS probably reduce medication errors compared to paper-based systems (OR 0.74, 95%CI 0.31 to 1.79; 2 studies, n=88).  Moderate-certainty evidence shows that, compared with standard CPOE/CDSS, improved CPOE/CDSS probably reduce medication errors (OR 0.85, 95%CI 0.74 to 0.97; 2 studies, n=630). Low-certainty evidence suggests that prioritised alerts provided by CPOE/CDSS may prevent ADEs compared to non-prioritised (inconsequential) alerts (MD 1.98, 95%CI 1.65 to 2.31; 1 study; participant numbers unavailable). Barcode identification of participants/medications Low-certainty evidence suggests that barcoding may reduce medication errors (OR 0.69, 95%CI 0.59 to 0.79; 2 studies, n=50,545). Reduced working hours Low-certainty evidence suggests that reduced working hours may reduce serious medication errors (RR 0.83, 95%CI 0.63 to 1.09; 1 study, n=634). However, the CI is compatible with important beneficial and detrimental effects. Feedback on prescribing errors Low-certainty evidence suggests that feedback on prescribing errors may reduce medication errors (OR 0.47, 95%CI 0.33 to 0.67; 4 studies, n=384). Dispensing system Low-certainty evidence suggests that dispensing systems in surgical wards may reduce medication errors (OR 0.61, 95%CI 0.47 to 0.79; 2 studies, n=1775). AUTHORS' CONCLUSIONS: Low- to moderate-certainty evidence suggests that, compared to usual care, medication reconciliation, CPOE/CDSS, barcoding, feedback and dispensing systems in surgical wards may reduce medication errors and ADEs. However, the results are imprecise for some outcomes related to medication reconciliation and CPOE/CDSS. The evidence for other interventions is very uncertain. Powered and methodologically sound studies are needed to address the identified evidence gaps. Innovative, synergistic strategies -including those that involve patients- should also be evaluated.

A systematic review and meta-analysis of the prevalence of therapeutic targets in cervical cancer.

Cervical Cancer (CC) is a significantly prevalent disease in developing countries. Currently, targeted therapies are not a primary standard of care in CC. This information could be crucial for developing directed therapies and patient screening for biomarkers that would allow personalised treatment of CC. This systematic review aimed to estimate the prevalence of potential therapeutic targets such as the epidermal growth factor receptor (EGFR) and the PI3K/Akt/mTOR and Ras/Raf/MAPK pathways in patients with CC, identified through genomic and non-genomic testing. Studies were identified through an ad-hoc search strategy from the available on MEDLINE (Ovid), CENTRAL, LILACS, SCOPUS, through the Clinical Trial registry on Clinicaltrials.gov, International Clinical Trials Registry Platform, RENIS (Argentine National Registry of Health Research) and grey literature sources. We included 74 studies which represented a total pool of 7,862 participants. Forty-five studies informed mutations of EGFR, with a combined positivity rate of 53% (95%CI: 45%-60%; I2 = 95%). Twenty studies informed the presence of mutations in PIK3CA with a combined positivity rate of 30% (95%CI: 21%-39%; I2 = 96%). Twenty-three studies reported a mutation in Ras, with a combined positivity rate of 14% (95%CI: 8%-21%; I2 = 95%). Raf mutations were informed in six studies. Six studies informed the presence of Akt mutations, two studies informed mTOR mutations and only one study reported mutations of MAPK. The most frequently described therapeutic targets were EGFR, and the PIK3CA and Ras pathways, though inconsistency in positivity rates was significant. Our study did not allow the identification of any specific clinical characteristics that might explain the observed heterogeneity. Despite the overall good quality of the included studies, the applicability of these results to patients' general population with CC is still unclear.

Ventriculo-peritoneal shunting devices for hydrocephalus.

BACKGROUND: Hydrocephalus is a common neurological disorder, caused by a progressive accumulation of cerebrospinal fluid (CSF) within the intracranial space that can lead to increased intracranial pressure, enlargement of the ventricles (ventriculomegaly) and, consequently, to brain damage. Ventriculo-peritoneal shunt systems are the mainstay therapy for this condition, however there are different types of shunt systems. OBJECTIVES: To compare the effectiveness and adverse effects of conventional and complex shunt devices for CSF diversion in people with hydrocephalus. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (2020 Issue 2); Ovid MEDLINE (1946 to February 2020); Embase (Elsevier) (1974 to February 2020); Latin American and Caribbean Health Science Information Database (LILACS) (1980 to February 2020); ClinicalTrials.gov; and World Health Organization International Clinical Trials Registry Platform. SELECTION CRITERIA: We selected randomised controlled trials or quasi-randomised trials of different types of ventriculo-peritoneal shunting devices for people with hydrocephalus. Primary outcomes included: treatment failure, adverse events and mortality. DATA COLLECTION AND ANALYSIS: Two review authors screened studies for selection, assessed risk of bias and extracted data. Due to the scarcity of data, we performed a Synthesis Without Meta-analysis (SWiM) incorporating GRADE for the quality of the evidence. MAIN RESULTS: We included six studies with 962 participants assessing the effects of standard valves compared to anti-syphon valves, other types of standard valves, self-adjusting CSF flow-regulating valves and external differential programmable pressure valves. All included studies started in a hospital setting and offered ambulatory follow-up. Most studies were conducted in infants or children with hydrocephalus from diverse causes. The certainty of the evidence for most comparisons was low to very low. 1. Standard valve versus anti-syphon valve Three studies with 296 randomised participants were included under this comparison. We are uncertain about the incidence of treatment failure in participants with standard valve and anti-syphon valves (very low certainty of the evidence). The incidence of adverse events may be similar in those with standard valves (range 0 to 1.9%) and anti-syphon valves (range 0 to 2.9%) (low certainty of the evidence). Mortality may be similar in those with standard valves (0%) and anti-syphon valves (0.9%) (RD 0.01%, 95% CI -0.02% to 0.03%, low certainty of the evidence). Ventricular size and head circumference may be similar in those with standard valves and anti-syphon valves (low certainty of the evidence). None of the included studies reported the quality of life of participants. 2. Comparison between different types of standard valves Two studies with 174 randomised participants were included under this comparison. We are uncertain about the incidence of treatment failure in participants with different types of standard valves (early postoperative period: RR 0.41, 95% CI 0.13 to 1.27; at 12 months follow-up: RR 1.17, 95% CI 0.72 to 1.92, very low certainty of the evidence). None of the included studies reported adverse events beyond those included under "treatment failure". We are uncertain about the effects of different types of standard valves on mortality (range 2% to 17%, very low certainty of the evidence). The included studies did not report the effects of these interventions on quality of life, ventricular size reduction or head circumference. 3. Standard valve versus self-adjusting CSF flow-regulating valve One study with 229 randomised participants addressed this comparison. The incidence of treatment failure may be similar in those with standard valves (42.98%) and self-adjusting CSF flow-regulating valves (39.13%) (low certainty of the evidence). The incidence of adverse events may be similar in those with standard valves (range 0 to 1.9%) and those with self-adjusting CSF flow-regulating valves (range 0 to 7.2%) (low certainty of the evidence). The included study reported no deaths in either group in the postoperative period. Beyond the early postoperative period, the authors stated that nine patients died (no disaggregated data by each type of intervention was available, low certainty of the evidence). The included studies did not report the effects of these interventions on quality of life, ventricular size reduction or head circumference. 4. External differential programmable pressure valve versus non-programmable valve One study with 377 randomised participants addressed this comparison. The incidence of treatment failure may be similar in those with programmable valves (52%) and non-programmable valves (52%)  (RR 1.02, 95% CI 0.84 to 1.24, low certainty of the evidence). The incidence of adverse events may be similar in those with programmable valves (6.19%) and non-programmable valves (6.01%) (RR 0.97, 95% CI 0.44 to 2.15, low certainty of the evidence). The included study did not report the effect of these interventions on mortality, quality of life or head circumference. Ventricular size reduction may be similar in those with programmable valves and non-programmable valves (low certainty of the evidence). AUTHORS' CONCLUSIONS: Standard shunt valves for hydrocephalus compared to anti-syphon or self-adjusting CSF flow-regulating valves may cause little to no difference on the main outcomes of this review, however we are very uncertain due to the low to very low certainty of evidence. Similarly, different types of standard valves and external differential programmable pressure valves versus non-programmable valves may be associated with similar outcomes. Nevertheless, this review did not include valves with the latest technology, for which we need high-quality randomised controlled trials focusing on patient-important outcomes including costs.

Adaptación y validación de la versión argentina de un instrumento para evaluar actividades de desarrollo profesional continuo / Adaptation and validation of the Argentine version of an instrument to assess continuing professional development activities

Introducción. Investigadores canadienses desarrollaron un cuestionario autoadministrado para indagar sobre la intención de los participantes de actividades de desarrollo profesional continuo (DPC) de transferir los conocimientos adquiridos en ámbitos áulicos a la práctica clínica. Su uso podría facilitar los procesos de mejora de la calidad en dichas actividades de DPC.Objetivo. Realizar la traducción y adaptación transcultural y validación del cuestionario REACTION (A theoRy-basEd instrument to assess the impACT of continuing profesional development activities on profesional behavIOr chaNge) para su uso en la Argentina, a partir de la versión original en inglés.Población y métodos. Se realizó la traducción y adaptación transcultural de los 12 ítems del instrumento, con un proceso de cinco pasos. La validez de constructo se exploró mediante el análisis factorial exploratorio, y la confiabilidad, a través del coeficiente de Cronbach y el coeficiente G.Resultados. La versión final del cuestionario se aplicó a una muestra de 133 médicos asistentes a 9 actividades presenciales de DPC de un hospital universitario de la Ciudad de Buenos Aires (edad promedio: 38 años; el 23,3 %, hombres; el 76 %, médicos de familia). El análisis factorial exploratorio arrojó 3 factores (influencia social, confianza en las capacidades propias y criterio ético). El coeficiente de Cronbach fue 0,82 y el coeficiente G fue 0,72.Conclusiones. Se realizó la adaptación y validación de la versión argentina del instrumento REACTION para evaluar el impacto del DPC enfocado en el entrenamiento de habilidades clínicas en la intención de los médicos de implementarlo en su práctica.

Introduction. Canadian researchers developed a self-administered questionnaire to ask participants of continuing professional development (CPD) activities about their intention to translate the knowledge acquired in the classroom into clinical practice. The questionnaire may facilitate quality improvement processes in such CPD activities.Objective. To translate, cross-culturally adapt and validate the original English REACTION questionnaire (A theoRy-basEd instrument to assess the impACT of continuing professional development activities on professional behavIOr chaNge) for its use in Argentina.Population and methods. The 12 questionnaire items were translated and cross-culturally adapted using a five-step process. The construct validity was assessed using an exploratory factor analysis, whereas reliability, with Cronbach's coefficient and the G coefficient.Results. The final questionnaire version was administered to a sample of 133 physicians who attended 9 CPD activities at a teaching hospital in the Autonomous City of Buenos Aires (average age: 38 years; 23.3 %, men; 76 %, family physicians). The exploratory factor analysis showed 3 factors (social influence, confidence in one's abilities, and ethical judgment). Cronbach's coefficient was 0.82 and the G coefficient, 0.72.Conclusions. The Argentine version of the REACTION questionnaire was adapted and validated to assess the impact of CPD centered on clinical skills training on physicians' intention to implement it in their practice

Adaptation and validation of the Argentine version of an instrument to assess continuing professional development activities. / Adaptación y validación de la versión argentina de un instrumento para evaluar actividades de desarrollo profesional continuo.

INTRODUCTION: Canadian researchers developed a self-administered questionnaire to ask participants of continuing professional development (CPD) activities about their intention to translate the knowledge acquired in the classroom into clinical practice. The questionnaire may facilitate quality improvement processes in such CPD activities. OBJECTIVE: To translate, cross-culturally adapt and validate the original English REACTION questionnaire (A theoRy-basEd instrument to assess the impACT of continuing professional development activities on professional behavIOr chaNge) for its use in Argentina. POPULATION AND METHODS: The 12 questionnaire items were translated and cross-culturally adapted using a five-step process. The construct validity was assessed using an exploratory factor analysis, whereas reliability, with Cronbach's coefficient and the G coefficient. RESULTS: The final questionnaire version was administered to a sample of 133 physicians who attended 9 CPD activities at a teaching hospital in the Autonomous City of Buenos Aires (average age: 38 years; 23.3 %, men; 76 %, family physicians). The exploratory factor analysis showed 3 factors (social influence, confidence in one's abilities, and ethical judgment). Cronbach's coefficient was 0.82 and the G coefficient, 0.72. CONCLUSIONS: The Argentine version of the REACTION questionnaire was adapted and validated to assess the impact of CPD centered on clinical skills training on physicians' intention to implement it in their practice.

Introducción. Investigadores canadienses desarrollaron un cuestionario autoadministrado para indagar sobre la intención de los participantes de actividades de desarrollo profesional continuo (DPC) de transferir los conocimientos adquiridos en ámbitos áulicos a la práctica clínica. Su uso podría facilitar los procesos de mejora de la calidad en dichas actividades de DPC. Objetivo. Realizar la traducción y adaptación transcultural y validación del cuestionario REACTION (A theoRy-basEd instrument to assess the impACT of continuing profesional development activities on profesional behavIOr chaNge) para su uso en la Argentina, a partir de la versión original en inglés. Población y métodos. Se realizó la traducción y adaptación transcultural de los 12 ítems del instrumento, con un proceso de cinco pasos. La validez de constructo se exploró mediante el análisis factorial exploratorio, y la confiabilidad, a través del coeficiente de Cronbach y el coeficiente G. Resultados. La versión final del cuestionario se aplicó a una muestra de 133 médicos asistentes a 9 actividades presenciales de DPC de un hospital universitario de la Ciudad de Buenos Aires (edad promedio: 38 años; el 23,3 %, hombres; el 76 %, médicos de familia). El análisis factorial exploratorio arrojó 3 factores (influencia social, confianza en las capacidades propias y criterio ético). El coeficiente de Cronbach fue 0,82 y el coeficiente G fue 0,72. Conclusiones. Se realizó la adaptación y validación de la versión argentina del instrumento REACTION para evaluar el impacto del DPC enfocado en el entrenamiento de habilidades clínicas en la intención de los médicos de implementarlo en su práctica.

Pharmacological interventions for treating chronic prostatitis/chronic pelvic pain syndrome: a Cochrane systematic review.

OBJECTIVE: To assess the effects of pharmacological therapies for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). PATIENTS AND METHODS: We performed a comprehensive search using multiple databases, trial registries, grey literature and conference proceedings with no restrictions on the language of publication or publication status. The date of the latest search of all databases was July 2019. We included randomised controlled trials. Inclusion criteria were men with a diagnosis of CP/CPPS. We included all available pharmacological interventions. Two review authors independently classified studies and abstracted data from the included studies, performed statistical analyses and rated quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods. The primary outcomes were prostatitis symptoms and adverse events. The secondary outcomes were sexual dysfunction, urinary symptoms, quality of life, anxiety and depression. RESULTS: We included 99 unique studies in 9119 men with CP/CPPS, with assessments of 16 types of pharmacological interventions. Most of our comparisons included short-term follow-up information. The median age of the participants was 38 years. Most studies did not specify their funding sources; 21 studies reported funding from pharmaceutical companies. We found low- to very low-quality evidence that α-blockers may reduce prostatitis symptoms based on a reduction in National Institutes of Health - Chronic Prostatitis Symptom Index (NIH-CPSI) scores of >2 (but <8) with an increased incidence of minor adverse events such as dizziness and hypotension. Moderate- to low-quality evidence indicates that 5α-reductase inhibitors, antibiotics, anti-inflammatories, and phytotherapy probably cause a small decrease in prostatitis symptoms and may not be associated with a greater incidence of adverse events. Intraprostatic botulinum toxin A (BTA) injection may cause a large reduction in prostatitis symptoms with procedure-related adverse events (haematuria), but pelvic floor muscle BTA injection may not have the same effects (low-quality evidence). Allopurinol may also be ineffective for reducing prostatitis symptoms (low-quality evidence). We assessed a wide range of interventions involving traditional Chinese medicine; low-quality evidence showed they may reduce prostatitis symptoms without an increased incidence in adverse events. Moderate- to high-quality evidence indicates that the following interventions may be ineffective for the reduction of prostatitis symptoms: anticholinergics, Escherichia coli lysate (OM-89), pentosan, and pregabalin. Low- to very low-quality evidence indicates that antidepressants and tanezumab may be ineffective for the reduction of prostatitis symptoms. Low-quality evidence indicates that mepartricin and phosphodiesterase inhibitors may reduce prostatitis symptoms, without an increased incidence in adverse events. CONCLUSIONS: Based on the findings of low- to very low-quality evidence, this review found that some pharmacological interventions such as α-blockers may reduce prostatitis symptoms with an increased incidence of minor adverse events such as dizziness and hypotension. Other interventions may cause a reduction in prostatitis symptoms without an increased incidence of adverse events while others were found to be ineffective.

COVID-19: presentación clínica en adultos / COVID-19: clinical features in adult patients

Este artículo resume las diferentes formas de presentación clínica de la enfermedad COVID-19 causada por el virus SARS-Co-2 documentadas fundamentalmente en las tres principales revisiones sistemáticas disponibles. Entre las manifestaciones clínicas de frecuente aparición se destacan la fiebre (83 %), la tos (60 %) y la fatiga (38 %), seguidas por las mialgias (29 %), el aumento de la producción del esputo (27 %) y la disnea (25 %). Entre los hallazgos de laboratorio,predominan el aumento de los valores de proteína C reactiva (69 %), la linfopenia (57 %) y el aumento de los niveles de lactato-deshidrogenasa (52 %). Respecto de las manifestaciones radiológicas, tienen especial importancia las opacificaciones en vidrio esmerilado (80 %), la neumonía bilateral (73 %) y la afectación de tres lóbulos pulmonares o más (57 %).Si bien la evidencia sintetizada tiene limitaciones, permite una aproximación actualizada a los conocimientos disponibles sobre la clínica de esta nueva enfermedad en la población adulta. (AU)

This article summarizes the different forms of clinical presentation of COVID-19, caused by the SARS-Co-2 virus, synthesizing the information collected mainly by three published systematic reviews. Frequent clinical manifestations include fever(83 %), cough (60 %), and fatigue (38 %), followed by myalgia (29 %), increased sputum production (27 %) and dyspnea(25 %). Among the laboratory findings, the most common are the increase in C-reactive protein values (69 %), lymphopenia (57 %) and the increase in lactate dehydrogenase levels (52 %).. Most remarkable radiological features include ground glass opacifications (80 %), bilateral pneumonia (73 %) and the involvement of three or more lung lobes (57 %). Although the synthesized evidence has limitations, it allows an updated approach to the available knowledge about the clinical symptoms of this new disease in the adult population. (AU)

[Prostate specific antigen utilization trends in an academic hospital in Argentina.] / Tendencia temporal de realización de Antígeno Prostático Específico en un Hospital Académico de Buenos Aires.

Background: Although prostate cancer (PC) screening with prostate-specific antigen (PSA) determination could decrease mortality, concerns about the potential risk of overdiagnosis led to recommendations against this preventive practice. The objective of this study was to describe the trend in PSA determinations in men between 40 and 79 years old, affiliated to a Health Maintenance Organization (HMO) of an academic hospital in the city of Buenos Aires, Argentina, and its association with the recommendations stated by the U.S. Preventive Task Force (USPSTF) and the Instituto Nacional del Cáncer in Argentina. Methods: We analyzed a time series of aggregated data. We calculated the annual age-standardized rates of accumulated determinations of PSA for every 100 affiliates without a personal history of PC. Additionally, we compared trends by age groups every 10 years. We used Joinpoint and MS Excel programs. Results: Between 2006 and 2011 there was a growing trend in the number of PSA determinations, with an annual average of + 1.2% (95% CI, -1.0 to +3.5). Between 2011 and 2015, the number of determinations began to decrease, with a percentage annual average of -4.1% (-6.9 to -1.1). Conclusion: We found a gradual decrease in PSA utilization in men between 40 and 79 years old after the 2012 USPSTF recommendation against prostate cancer screening.

Introducción: Aunque el rastreo del cáncer de próstata (CP) mediante el dosaje sérico de antígeno prostático específico (en inglés, PSA) podría disminuir la mortalidad, la preocupación por su potencial riesgo de sobrediagnóstico llevó a desaconsejar su realización. El objetivo de este estudio fue describir la tendencia temporal de realización de esta práctica en varones entre 40 y 79 años afiliados a un seguro privado de salud de la ciudad de Buenos Aires, en relación con las recomendaciones de la Fuerza de Tareas Preventivas de los EE.UU. (USPSTF) y el Instituto Nacional del Cáncer de Argentina. Métodos. Serie temporal de datos agregados. Se calcularon las tasas anuales estandarizadas de incidencia acumulada de realización de PSA cada 100.000 afiliados sin antecedentes personales de CP, en el período 2006 a 2015. Adicionalmente, se construyeron curvas de tendencia por grupos etarios cada 10 años. Se utilizaron los programas Joinpoint y MS Excel. Resultados. Entre 2006 y 2011 hubo una tendencia creciente en la realización de PSA, con un promedio anual porcentual de +1,2% (IC 95%, -1,0 a +3,5). Entre 2011 y 2015, el número de determinaciones comenzó a decrecer, con un promedio anual porcentual de -4,1% (-6,9 a -1,1). Conclusión. En un hospital académico de Buenos Aires se observó un descenso paulatino en la realización de PSA en varones entre 40 y 79 años luego de la recomendación de 2012 en contra del rastreo del CP en todos los grupos etarios. Métodos: Serie temporal de datos agregados. Se calcularon las tasas anuales estandarizadas de incidencia acumulada de realización de PSA cada 100.000 afiliados sin antecedentes personales de CP, en el período 2006 a 2015. Adicionalmente, se construyeron curvas de tendencia por grupos etarios cada 10 años. Se utilizaron los programas Joinpoint y MS Excel. Resultados. Entre 2006 y 2011 hubo una tendencia creciente en la realización de PSA, con un promedio anual porcentual de +1,2% (IC 95%, -1,0 a +3,5). Entre 2011 y 2015, el número de determinaciones comenzó a decrecer, con un promedio anual porcentual de -4,1% (-6,9 a -1,1). Conclusión. En un hospital académico de Buenos Aires se observó un descenso paulatino en la realización de PSA en varones entre 40 y 79 años luego de la recomendación de 2012 en contra del rastreo del CP en todos los grupos etarios. Resultados: Entre 2006 y 2011 hubo una tendencia creciente en la realización de PSA, con un promedio anual porcentual de +1,2% (IC 95%, -1,0 a +3,5). Entre 2011 y 2015, el número de determinaciones comenzó a decrecer, con un promedio anual porcentual de -4,1% (-6,9 a -1,1). Conclusión. En un hospital académico de Buenos Aires se observó un descenso paulatino en la realización de PSA en varones entre 40 y 79 años luego de la recomendación de 2012 en contra del rastreo del CP en todos los grupos etarios. Conclusión: En un hospital académico de Buenos Aires se observó un descenso paulatino en la realización de PSA en varones entre 40 y 79 años luego de la recomendación de 2012 en contra del rastreo del CP en todos los grupos etarios.

Pharmacological interventions for treating chronic prostatitis/chronic pelvic pain syndrome.

BACKGROUND: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common disorder in which the two main clinical features are pelvic pain and lower urinary tract symptoms. There are currently many approaches for its management, using both pharmacological and non-pharmacological interventions. The National Institute of Health - Chronic Prostatitis Symptom Index (NIH-CPSI) score is a validated measure commonly used to measure CP/CPPS symptoms. We considered a 25% decrease of NIH-CPSI baseline score or a six-point reduction as MCID. OBJECTIVES: To assess the effects of pharmacological therapies for chronic prostatitis/chronic pelvic pain syndrome. SEARCH METHODS: We performed a comprehensive search using CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, trial registries, grey literature and conference proceedings, with no restrictions on the language of publication or publication status. The date of the latest search of all databases was July 2019. SELECTION CRITERIA: We included randomised controlled trials. Inclusion criteria were men with a diagnosis of CP/CPPS. We included all available pharmacological interventions compared to placebo or in head-to-head comparisons. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed study eligibility, extracted data, and assessed the risks of bias of included studies. We assessed the quality of the evidence (QoE) using the GRADE approach. MAIN RESULTS: We included 99 unique studies in 9119 men with CP/CPPS, with assessments of 16 types of pharmacological interventions. Unless stated otherwise, our comparisons were based on short-term follow-up (less than 12 months). Most studies did not specify their funding sources; 21 studies reported funding from pharmaceutical companies.1. Alpha blockers: (24 studies, 2061 participants). We are uncertain about the effects of these drugs on prostatitis symptoms when compared to placebo at short-term follow-up (mean difference (MD) in total NIH-CPSI score -5.01, 95% confidence interval (CI) -7.41 to -2.61; 18 studies, 1524 participants, very low QoE) and at long-term follow-up (MD -5.60, 95% CI -10.89 to -0.32; 4 studies, 235 participants, very low QoE). Alpha blockers may be associated with an increased incidence of adverse events, such as dizziness and postural hypotension (risk ratio (RR) 1.60, 95% CI 1.09 to 2.34; 19 studies, 1588 participants; low QoE). Alpha blockers probably result in little to no difference in sexual dysfunction, quality of life and anxiety and depression (moderate to low QoE).2. 5-alpha reductase inhibitors (5-ARI): (2 studies, 177 participants). Finasteride probably reduces prostatitis symptoms compared to placebo (NIH-CPSI score MD -4.60, 95% CI -5.43 to -3.77; 1 study, 64 participants; moderate QoE) and may not be associated with an increased incidence of adverse events (low QoE). There was no information on sexual dysfunction, quality of life or anxiety and depression.3. Antibiotics: (6 studies, 693 participants). Antibiotics (quinolones) may reduce prostatitis symptoms compared to placebo (NIH-CPSI score MD -2.43, 95% CI -4.72 to -0.15; 5 studies, 372 participants; low QoE) and are probably not associated with an increased incidence in adverse events (moderate QoE). Antibiotics probably result in little to no difference in sexual dysfunction and quality of life (moderate QoE). There was no information on anxiety or depression.4. Anti-inflammatories: (7 studies, 585 participants). Anti-inflammatories may reduce prostatitis symptoms compared to placebo (NIH-CPSI scores MD -2.50, 95% CI -3.74 to -1.26; 7 studies, 585 participants; low QoE) and may not be associated with an increased incidence in adverse events (low QoE). There was no information on sexual dysfunction, quality of life or anxiety and depression.5. Phytotherapy: (7 studies, 551 participants). Phytotherapy may reduce prostatitis symptoms compared to placebo (NIH-CPSI scores MD -5.02, 95% CI -6.81 to -3.23; 5 studies, 320 participants; low QoE) and may not be associated with an increased incidence in adverse events (low QoE). Phytotherapy may not improve sexual dysfunction (low QoE). There was no information on quality of life or anxiety and depression.6. Botulinum toxin A (BTA): Intraprostatic BTA injection (1 study, 60 participants) may cause a large reduction in prostatitis symptom (NIH-CPSI scores MD -25.80, 95% CI -30.15 to -21.45), whereas pelvic floor muscle BTA injection (1 study, 29 participants) may not reduce prostatitis symptoms (low QoE). Both comparisons used a placebo injection. These interventions may not be associated with an increased incidence in adverse events (low QoE). There was no information on sexual dysfunction, quality of life or anxiety and depression.7. Allopurinol: (2 studies, 110 participants). Allopurinol may result in little to no difference in prostatitis symptoms and adverse events when compared to placebo (low QoE). There was no information on sexual dysfunction, quality of life or anxiety and depression.8. Traditional Chinese medicine (TCM): (7 studies, 835 participants); TCM may reduce prostatitis symptoms (NIH-CPSI score, MD -3.13, 95% CI -4.99 to -1.28; low QoE) and may not be associated with an increased incidence in adverse events (low QoE). TCM probably does not improve sexual dysfunction (moderate QoE) and may not improve symptoms of anxiety and depression (low QoE). There was no information on quality of life.The most frequent reasons for downgrading the QoE were study limitations, inconsistency and imprecision. We found few trials with active comparators. AUTHORS' CONCLUSIONS: We found low- to very low-quality evidence that alpha blockers, antibiotics, 5-ARI, anti-inflammatories, phytotherapy, intraprostatic BTA injection, and traditional Chinese medicine may cause a reduction in prostatitis symptoms without an increased incidence of adverse events in the short term, except for alpha blockers which may be associated with an increase in mild adverse events. We found few trials with active comparators and little evidence of the effects of these drugs on sexual dysfunction, quality of life or anxiety and depression. Future clinical trials should include a full report of their methods, including adequate masking, consistent assessment of all patient-important outcomes, including potential treatment-related adverse events, and appropriate sample sizes.

Propiedades psicométricas y características operativas de la versión adaptada al castellano del cuestionario CRAFFT en adolescentes del conurbano bonaerense / Psychometric properties and operating characteristics of the Spanish-adapted version of the CRAFFT questionnaire in adolescents from Greater Buenos Aires

Introducción. El cuestionario Car, Relax, Alone, Forget, Family and Friends, Trouble (CRAFFT) es un instrumento de tamizaje de riesgo de consumo problemático, abuso o dependencia de alcohol y sustancias en adolescentes. Si bien cuenta con una versión validada y adaptada al castellano para su utilización en adolescentes argentinos (CRAFFTa), su uso no puede generalizarse, ya que no ha sido evaluado en diferentes contextos socioculturales. Objetivo. Evaluar la transferibilidad del CRAFFTa como herramienta de pesquisa de consumo problemático, abuso y dependencia de alcohol y otras sustancias en una población adolescente de bajo nivel socioeconómico. Población y métodos. Se encuestó en forma anónima a una muestra de adolescentes de una localidad de bajos recursos del conurbano bonaerense que concurrían a dos escuelas secundarias. Se aplicó el cuestionario CRAFFT adaptado al español y validado para su uso en Argentina, y se empleó el cuestionario Problem Oriented Screening Instrument for Teenagers substance use and abuse subscale (POSITuas) como prueba de referencia. Resultados. Se obtuvieron 146 cuestionarios completos (tasa de respuesta del 89,6 %). La confiabilidad fue 0,681; validez de criterio: 0,697; sensibilidad: 93,4; especificidad: 72,5; precisión: 0,886. Valor predictivo positivo: 0,898; y negativo: 0,966. La fiabilidad compuesta fue 0,872; varianza media extractada: 0,718. La validez convergente fue aceptable en el análisis factorial confirmatorio, y se empleó una estructura unifactorial. Conclusiones. Las características operativas del CRAFFTa son aceptables para su uso en el rastreo de consumo problemático de alcohol y abuso de sustancias en una población adolescente de bajos recursos.

Introduction: The Car, Relax, Alone, Forget, Family and Friends, Trouble (CRAFFT) questionnaire is an instrument used in the screening for problematic alcohol and substance use, abuse or dependence in adolescents. While there is a Spanish-adapted and validated version for Argentine adolescents (CRAFFTa), it cannot be applied indiscriminately because it has not been assessed in different sociocultural settings. Objective: To assess the transferability of the CRAFFTa as a screening tool for problematic alcohol and drug use, abuse or dependence in an adolescent population of low socio-economic level. Population and methods: An anonymous survey was administered to low-income adolescents living in Greater Buenos Aires and attending two secondary schools. The Spanish-adapted version of the CRAFFT questionnaire, validated for its use in Argentina, was administered, while the Problem Oriented Screening Instrument for Teenagers, substance use and abuse subscale (POSITuas) questionnaire was used as a reference test. Results: A total of 146 questionnaires were completed (completion rate: 89.6 %). Reliability was 0.681; criterion validity: 0.697; sensitivity: 93.4; specificity: 72.5; precision: 0.886; positive predictive value: 0.898; negative predictive value: 0.966. Compound reliability was 0.872; average variance extracted: 0.718. Convergent validity was acceptable in the confirmatory factor analysis, and a single-factor structure was used. Conclusions: The operating characteristics of the CRAFFTa questionnaire are acceptable for its use in the screening for problematic alcohol and substance use, abuse or dependence in a low-income adolescent population.

Non-pharmacological interventions for treating chronic prostatitis/chronic pelvic pain syndrome: a Cochrane systematic review.

OBJECTIVE: To assess the effects of non-pharmacological therapies for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). PATIENTS AND METHODS: We performed a comprehensive search using multiple databases, trial registries, grey literature and conference proceedings with no restrictions on the language of publication or publication status. The date of the latest search of all databases was August 2017. We included randomized controlled trials in men with a diagnosis of CP/CPPS. We included all available non-pharmacological interventions. Two review authors independently classified studies and abstracted data from the included studies, performed statistical analyses and rated quality of evidence (QoE) according to the Grading of Recommendations Assessment, Development and Evaluation methods. The primary outcomes were prostatitis symptoms and adverse events. The secondary outcomes were sexual dysfunction, urinary symptoms, quality of life, anxiety and depression. RESULTS: We included 38 unique studies in 3290 men with CP/CPPS across 23 comparisons, reporting outcomes mostly at short-term follow-up. Our analysis showed that acupuncture probably leads to clinically meaningful reduction in prostatitis symptoms compared with a sham procedure (mean difference [MD] in total National Institutes of Health - Chronic Prostatitis Symptom Index [NIH-CPSI] score -5.79, 95% confidence interval [CI] -7.32 to -4.26, moderate QoE). Acupuncture may result in little or no difference in adverse events (low QoE). Acupuncture may also lead to a clinically meaningful reduction in prostatitis symptoms compared with standard medical therapy (MD -6.05, 95% CI -7.87 to -4.24, two studies, 78 participants, low QoE). Lifestyle modifications may be associated with a reduction in prostatitis symptoms compared with control (risk ratio for improvement in NIH-CPSI scores 3.90, 95% CI 2.20 to 6.92, very low QoE), but we found no information regarding adverse events. A physical activity programme may cause a small reduction in prostatitis symptoms compared with control (NIH-CPSI score MD -2.50, 95% CI -4.69 to -0.31, low QoE), but we found no information regarding adverse events. It was uncertain whether prostatic massage reduces or increases prostatitis symptoms compared with control (very low QoE) and we found no information regarding adverse events. Extracorporeal shockwave therapy reduces prostatitis symptoms compared with control (NIH-CPSI score MD -6.18, 95% CI -7.46 to -4.89, high QoE), but these results may not be sustained at medium-term follow-up (low QoE). This treatment may not be associated with a greater incidence of adverse events (low QoE). Transrectal thermotherapy, alone or in combination with medical therapy, may decrease prostatitis symptoms slightly when compared with medical therapy alone (NIH-CPSI score MD -2.50, 95% CI -3.82 to -1.18, low QoE). One included study reported that participants may experience transient adverse events. CONCLUSIONS: Based on the findings with moderate to high QoE, this review found that some non-pharmacological interventions, such as acupuncture and extracorporeal shockwave therapy, are likely to result in a decrease in prostatitis symptoms and may not be associated with a greater incidence of adverse events. The QoE for most other comparisons was predominantly low. Future clinical trials should include a full report of their methods, including adequate masking, consistent assessment of all patient-important outcomes including potential treatment-related adverse events and appropriate sample sizes.

Qué significa vivir con diabetes en una comunidad del conurbano bonaerense: representaciones sociales de la diabetes mellitus tipo 2 / What it means to live with diabetes in a community of Buenos Aires: social representations of type 2 diabetes mellitus

Objetivo: conocer e interpretar las representaciones sociales que tienen las personas con diabetes mellitus (DM) tipo 2 en una comunidad de bajo nivel socioeconómico del Gran Buenos Aires. Metodología: investigación cualitativa, tipo estudio de caso. Se realizaron entrevistas semiestructuradas a personas con diagnóstico de DM tipo 2, atendidas en un centro de atención primaria del Bajo Boulogne, partido de San Isidro, Buenos Aires. Mediante un muestreo teórico o por conveniencia, a partir de las historias clínicas generadas entre enero de 2001 y julio de 2017. Se incluyeron personas con diagnóstico reciente y otras con más de 15 años de evolución, hasta la saturación del discurso. Se realizó un análisis temático. Resultados: se realizaron 20 entrevistas. La mayoría de las personas entrevistadas tenían entre 60 y 69 años y eran de sexo femenino. La DM es vivida como una enfermedad que no tiene cura y que no condiciona a quienes la padecen en lo cotidiano. No impresionó ser una carga, excepto para las personas insulinizadas, quienes le asignan una connotación negativa a esa terapia. No encontramos diferencias de acuerdo con el sexo, la edad o los años de evolución. Los entrevistados asociaron la DM con malos hábitos alimentarios y escasa o nula actividad física. Conclusiones: en esta comunidad, la DM es vivida con naturalidad, en especial por quienes llevan años padeciéndola. La red familiar constituye la principal fuente de apoyo, acompañamiento, contención y provisión de cuidados. No se identificaron otras redes además de la familia o el sistema médico tradicional. (AU)

Objective: to recognize and to understand the social representations of people with type 2 diabetes mellitus (DM) in a community with a low socioeconomic level of suburban Buenos Aires. Methods: qualitative research, case study type. Semi-structured interviews were administered to people diagnosed with type 2 DM, who attended a primary care center in Bajo Boulogne, San Isidro district, Buenos Aires. Through a theoretical or convenience sampling, from the clinical records generated between January 2001 and July 2017. We included people with a recent diagnosis and others with more than 15 years of evolution, until speech saturation. We carried out a thematic analysis. Results: we conducted 20 interviews. Most of the people were aged between 60 and 69 years and were female. DM is lived as a disease without a cure and which does not condition the daily activities of people who suffer from it. It did not impress to be a burden, except for insulinized people, who assigned a negative connotation to that therapy. We did not find differences according to sex, age or years of evolution. Patients associated DM with poor eating habits and little or no physical activity. Conclusions: in this community, DM is lived naturally, especially by those who have been suffering from it for years. The family network constitutes the main source of support, accompaniment, containment, and provision of care. No other networks were identified, besides the family or the traditional medical system. (AU)

El cuidado de la salud del Ejército de los Andes del general San Martín / The health care of the Army of Andes of General San Martín

A través de la revisión de documentos históricos y otras fuentes bibliográficas, y desde la perspectiva de la enfermería, se describen los recursos y prácticas sanitarias con que contaba el equipo de salud que acompañó al cuerpo del Ejército de los Andes al mando del general José de San Martín desde el inicio del cruce de los Andes el 19 de enero en las Provincias Unidas del Río de la Plata, hasta finalizada la batalla de Chacabuco, en la Capitanía General de Chile, el 12 de febrero de 1817. Este trabajo nos permite conocer el trabajo de los primeros sanitarios militares que asistieron en el cuidado de los soldados de los ejércitos patrios y contribuir así a difundir la historia de la Medicina Argentina. (AU)

Through the review of historical documents and other bibliographic sources, and from the perspective of nursing, we describe the health resources and practices held by the health team that accompanied the Army of Los Andes under the command of General José de San Martín, from the start of crossing Los Andes on January 19th in the Provincias Unidas del Río de la Plata, to finish in the battle of Chacabuco, in the General Captaincy of Chile on February 12th, 1817. This work allows us to know the work of the first military health professionals who assisted in the care of the soldiers of the patriotic armies and contribute to spread the history of the Argentine Medicine. (AU)