Comparison of dyad versus individual simulation-based training on stress, anxiety, cognitive load, and performance: a randomized controlled trial.

BACKGROUND: Dyad learning has been shown to be an effective tool for teaching procedural skills, but little is known about how dyad learning may impact the stress, anxiety, and cognitive load that a student experiences when learning in this manner. In this pilot study, we investigate the relationship between dyad training on stress, anxiety, cognitive load, and performance in a simulated bradycardia scenario. METHODS: Forty-one fourth-year medical school trainees were randomized as dyads (n = 24) or individuals (n = 17) for an education session on day 1. Reassessment occurred on day 4 and was completed as individuals for all trainees. Primary outcomes were cognitive load (Paas scale), stress (Cognitive Appraisal Ratio), and anxiety levels (abbreviated State-Trait Anxiety Inventory). Secondary outcomes were time-based performance metrics. RESULTS: On day 1 we observed significant differences for change in anxiety and stress measured before and after the training scenario between groups. Individuals compared to dyads had larger mean increases in anxiety, (19.6 versus 7.6 on 80-point scale, p = 0.02) and stress ratio (1.8 versus 0.9, p = 0.045). On the day 4 post-intervention assessment, no significant differences were observed between groups. Secondary outcomes were significant for shorter time to diagnosis of bradycardia (p = 0.01) and time to initiation of pacing (p = 0.04) in the dyad group on day 1. On day 4, only time to recognizing the indication for pacing was significantly shorter for individual training (hazard ratio [HR] = 2.26, p = 0.02). CONCLUSIONS: Dyad training results in lower stress and anxiety levels with similar performance compared to individual training.

"Residents get no satisfaction" a problem to face during internal medicine rotations: development and psychometric properties of the IMPRINT-15.

Clinical rotations are an essential part of Internal Medicine (IM) residency programmes, where curricular objectives are carried out. To our knowledge, there are no validated instruments to assess IM clinical rotations. Our objective was to develop an instrument for residents to assess the quality of clinical rotations in an IM residency programme, and to test the psychometric properties of the instrument. A mixed methodology was used, including qualitative and quantitative phases. Items were proposed by a group of experts based on previously identified residency needs, followed by a quantitative phase to generate consensus among educators and residents to define which items would be included in the instrument (Delphi panel). After generating the instrument, psychometric tests were performed to assess construct validity (factor analysis) and reliability (Raykov's reliability coefficient). We obtained a 15-item instrument after two Delphi rounds: Internal Medicine Program Instrument 15-items (IMPRINT-15). Sixty-two residents answered 428 surveys using a Likert scale during 7 months (response rate 98.9%). The median score was 4.3 (IQR 3.9-4.7) (scale from 1 to 5). The factor analysis showed two domains in the clinical rotation assessment: (1) teaching and care activities; (2) evaluation and feedback. The instrument is reliable with Raykov's reliability coefficient of 0.86. Also, Raykov's reliability coefficient for the domains were 0.89 and 0.83, respectively. The IMPRINT-15 instrument is a bi-dimensional, valid and reliable questionnaire to evaluate the perceived quality by residents of the IM clinical rotations. Also, it constitutes the first validated instrument in this field worldwide.

Personalized video feedback improves suturing skills of incoming general surgery trainees.

BACKGROUND: The American Board of Surgery encourages graduating medical students to prepare for surgical residency before day 1. We sought to determine the impact of personalized video feedback on an advance preparation task. METHODS: We conducted a nonrandomized study comparing video feedback versus no feedback. We sent incoming surgical interns a preparatory package 2 months before starting residency. Trainees video-recorded themselves performing a subcuticular wound closure, 3 times at 3-week intervals, and submitted these for appraisal. A staff surgeon provided personalized feedback on each video as a narrated voiceover. The voiced-over videos were then returned to trainees. We compared performance (time and completion rate) on suturing in a multistation assessment against residents from the previous year (no-feedback group). RESULTS: The feedback group had a higher completion rate for the suturing assessment than the no-feedback group (23/28 [82%] vs. 8/27 [30%], P < .0001). The feedback group also completed the suturing station at a faster rate than those without feedback (hazard ratio 4.9 [95% confidence interval (CI): 2.2,11.2), P < .0001). Global rating scores were significantly higher for the feedback group (mean difference [5-point scale] = 0.7 [95% CI: 0.3, 1.1]). However, Objective Structured Assessment of Technical Skills scores indicated no significant difference between groups (mean difference [5-point scale] = 0.3 [95% CI: 0.0, 0.6]). Within the feedback group, we found significant improvement from baseline to final performances (mean difference = 109 seconds [95% CI: 79, 140]). CONCLUSION: Personalized narrated feedback as part of a home-based advance preparation package for incoming residents is associated with higher performance on early objective assessments.

Trends in P Value, Confidence Interval, and Power Analysis Reporting in Health Professions Education Research Reports: A Systematic Appraisal.

PURPOSE: To characterize reporting of P values, confidence intervals (CIs), and statistical power in health professions education research (HPER) through manual and computerized analysis of published research reports. METHOD: The authors searched PubMed, Embase, and CINAHL in May 2016, for comparative research studies. For manual analysis of abstracts and main texts, they randomly sampled 250 HPER reports published in 1985, 1995, 2005, and 2015, and 100 biomedical research reports published in 1985 and 2015. Automated computerized analysis of abstracts included all HPER reports published 1970-2015. RESULTS: In the 2015 HPER sample, P values were reported in 69/100 abstracts and 94 main texts. CIs were reported in 6 abstracts and 22 main texts. Most P values (≥77%) were ≤.05. Across all years, 60/164 two-group HPER studies had ≥80% power to detect a between-group difference of 0.5 standard deviations. From 1985 to 2015, the proportion of HPER abstracts reporting a CI did not change significantly (odds ratio [OR] 2.87; 95% CI 1.04, 7.88) whereas that of main texts reporting a CI increased (OR 1.96; 95% CI 1.39, 2.78). Comparison with biomedical studies revealed similar reporting of P values, but more frequent use of CIs in biomedicine. Automated analysis of 56,440 HPER abstracts found 14,867 (26.3%) reporting a P value, 3,024 (5.4%) reporting a CI, and increased reporting of P values and CIs from 1970 to 2015. CONCLUSIONS: P values are ubiquitous in HPER, CIs are rarely reported, and most studies are underpowered. Most reported P values would be considered statistically significant.

Accurate surgical skills evaluation: Does it mandate raters have a medical background?

BACKGROUND: Surgeons rarely have time to assess/rate trainee performance. From a 10 year-experience of implementing OSCE style assessments, we hypothesize that the accurate scoring of interns in selected tests is not affected by the rater's medical background. METHODS: A prospective collection of quantitative scoring data by both medical school graduates and college students was compared. Each rater underwent training and then watched three videos of actors performing in each of two OSCE stations and individually scored them. RESULTS: Twelve college students and 16 medical graduates participated. There was no difference in the mean scores between rating groups for chest tube insertion (Video 1: 1.7 vs. 2.0; Video 2: 2.9 vs 3.1; Video 3: 6.1 vs 6.1; p = 0.8) and cricothyrotomy (Video 1: 4.0 vs 4.5; Video 2: 4.8 vs 5.1; Video 3: 9.2 vs 9.1; p = 0.7). CONCLUSION: Accurate scoring of surgical performance does not mandate a medical background. Given the limited availability of attending surgeons for assessments, use of validated, simple checklists can help raters with minimal medical experience perform assessments proficiently.

Surgery Website as a 24/7 Adjunct to a Surgical Curriculum.

OBJECTIVE: Successfully teaching duty hour restricted trainees demands engaging learning opportunities. Our surgical educational website and its associated assets were assessed to understand how such a resource was being used. DESIGN: Our website was accessible to all Mayo Clinic employees via the internal web network. Website access data from April 2015 through October 2016 were retrospectively collected using Piwik. SETTING: Academic, tertiary care referral center with a large general surgery training program. Mayo Clinic, Rochester, MN. PARTICIPANTS: A total of 257 Mayo Clinic employees used the website. RESULTS: The website had 48,794 views from 6313 visits by 257 users who spent an average of 14 ± 11 minutes on the website. Our website houses 295 videos, 51 interactive modules, 14 educational documents, and 7 flashcard tutorials. The most popular content type was videos, with a total of 30,864 views. The most popular visiting time of the day was between 8 pm and 9 pm with 6358 views (13%), and Thursday was the most popular day with 17,907 views (37%).  A total of 78% of users accessed content beyond the homepage. Average visits peaked in relation to 2 components of our curriculum: a 240% increase one day before our biannual intern simulation assessments, and a 61% increase one day before our weekly conducted Friday simulation sessions. Interns who rotated on the service of the staff surgeon who actively endorses the website had 93% more actions per visit as compared to other users. The highest clicks were on the home banner for our weekly simulation session pre-emptive videos, followed by "groin anatomy," and "TEP hernia repair" videos. CONCLUSIONS: Our website acted as a "just-in-time" accessible portal to reliable surgical information. It supplemented the time sensitive educational needs of our learners by serving as a heavily used adjunct to 3 components of our surgical education curriculum: weekly simulation sessions, biannual assessments, and clinical rotations.

Personalized Video Feedback and Repeated Task Practice Improve Laparoscopic Knot-Tying Skills: Two Controlled Trials.

PURPOSE: Compare the effect of personalized feedback (PF) vs. task demonstration (TD), both delivered via video, on laparoscopic knot-tying skills and perceived workload; and evaluate the effect of repeated practice. METHOD: General surgery interns and research fellows completed four repetitions of a simulated laparoscopic knot-tying task at one-month intervals. Midway between repetitions, participants received via e-mail either a TD video (demonstration by an expert) or a PF video (video of their own performance with voiceover from a blinded senior surgeon). Each participant received at least one video per format, with sequence randomly assigned. Outcomes included performance scores and NASA Task Load Index (NASA-TLX) scores. To evaluate the effectiveness of repeated practice, scores from these trainees on a separate delayed retention test were compared against historical controls who did not have scheduled repetitions. RESULTS: Twenty-one trainees completed the randomized study. Mean change in performance scores was significantly greater for those receiving PF (difference = 23.1 of 150 [95% confidence interval (CI): 0, 46.2], P = .05). Perceived workload was also significantly reduced (difference = -3.0 of 20 [95% CI: -5.8, -0.3], P = .04). Compared with historical controls (N = 93), the 21 with scheduled repeated practice had higher scores on the laparoscopic knot-tying assessment two weeks after the final repetition (difference = 1.5 of 10 [95% CI: 0.2, 2.8], P = .02). CONCLUSIONS: Personalized video feedback improves trainees' procedural performance and perceived workload compared with a task demonstration video. Brief monthly practice sessions support skill acquisition and retention.

The ACGME Case Log System May Not Accurately Represent Operative Experience Among General Surgery Interns.

OBJECTIVE: To assess if the Accreditation Council for Graduate Medical Education (ACGME) case log system accurately captures operative experience of our postgraduate year 1 (PGY-1) residents. DESIGN: ACGME case log information was retrospectively obtained for 5 cohorts of PGY-1 residents (2011-2015) and compared to the number of operative cases captured by an institutional automated operative case report system, Surgical Access Utility System (SAUS). SAUS automatically captures all surgical team members who are listed in the operative dictation for a given case, including interns. A paired t-test analysis was used to compare number of cases coded between the 2 systems. SETTING: Academic, tertiary care referral center with a large general surgery training program. PARTICIPANTS: PGY-1 general surgery trainees (interns) from the years 2011-2015. RESULTS: Forty-nine PGY-1 general surgery residents were identified over a 5-year period. Mean operative case volume per intern, per year, captured by the automated SAUS was 176.5 ± 28.1 (SD) compared to 126.3 ± 58.0 ACGME cases logged (mean difference = 50.2 cases, p < 0.001). CONCLUSIONS: ACGME case log data may not accurately reflect the actual operative experience of our PGY-1 residents. If such data holds true for other general surgery training programs, the true impact of duty hour regulations on operative volume may be unclear when using the ACGME case log data. This current standard approach for using ACGME case logs as a representation of operative experience requires further scrutiny and potential revision to more accurately determine operative experience for accreditation purposes.

At Home Preresidency Preparation for General Surgery Internship: A Pilot Study.

OBJECTIVE: To create a novel "at-home" preresidency preparatory adjunct for medical students entering surgical residency. DESIGN: Preparatory resources were mailed to match medical students before residency matriculation in 2015. This included "how-to" videos, low-cost models, and surgical instruments for 5 "stations" (arterial blood gas analysis, anatomy and imaging knowledge, knot tying ability, and suturing dexterity) of our program's biannual general surgery intern objective assessment activity (Surgical Olympics: total 13 stations, 10 points each). Scores from 2015 were compared with 2014 historical controls in a retrospective manner using the Student's t-test. SETTING: Academic, tertiary care referral center with a large general surgery training program. PARTICIPANTS: Postgraduate year 1 general surgery trainees (interns) from the years 2014 and 2015. RESULTS: Twenty-six interns participated in the 2015 assessment and were compared to thirty-two 2014 interns. Overall mean scores were low, but higher (19.7 vs. 15.4, p = 0.04) in the 2015 class. The largest increase was noted in the anatomy knowledge station (mean = 5.0 vs. 1.9, p < 0.01). Scores in stations assessing technical competence were similar to controls. The number of perfect scores among the 5 stations was higher (10 vs. 5) in the 2015 group. Mean scores from the other 8 stations, for which no resources were mailed, showed no difference (29.3 vs. 28.3, p = 0.75). CONCLUSIONS: Enacting a simple, home-based curriculum for medical students before surgical residency, improved performance on early knowledge assessments.

Disfuncionalidad antioxidante de las lipoproteínas de alta densidad (HDL) en pacientes diabéticos descompensados / Antioxidant dysfunctionality of high-density lipoproteins (hdl) in decompensated diabetic patients

Introducción: las lipoproteínas de alta densidad (HDL) tienen un importante efecto protector cardiovascular mediado por su función durante el transporte reverso del colesterol, así como por otras actividades, incluyendo una significativa acción antiinflamatoria y antioxidante. La funcionalidad antiinflamatoria y antioxidante de las HDL está alterada en los pacientes diabéticos crónicos estables, aunque no existe mayor información en caso de una crisis hiperglicémica. Objetivo: determinar si durante un estado de descompensación diabética aguda las partículas de HDL exhiben un deterioro de su función antioxidante y si esta logra recuperarse una vez resuelto el cuadro agudo. Métodos: la actividad antioxidante de las HDL se midió mediante un ensayo de fluorescencia in vitro en muestras plasmáticas de pacientes diabéticos con descompensación aguda obtenidas tanto al ingreso, alcanzada la resolución intrahospitalaria del evento agudo, así como en un control ambulatorio post-hospitalización. Como comparación, se analizaron partículas de HDL de algunos sujetos sanos como condición control. Resultados: la actividad antioxidante de las HDL en pacientes con descompensación diabética aguda fue significativamente menor a la observada en el grupo control sano, y esta se fue recuperando progresivamente hasta normalizarse en el momento del control ambulatorio. La crisis hiperglicémica también demostró una baja actividad plasmática de la enzima antioxidante paraoxonasa-1, la cual aumentó significativamente en el control ambulatorio. Conclusión: las partículas de HDL presentes en pacientes con una descompensación diabética aguda presentan reducción significativa y reversible de su capacidad antioxidante, probablemente como consecuencia de una alteración en la actividad de la paraoxonasa-1 (AU)

Introduction: high density lipoproteins (HDL) have important cardiovascular protective effects mediated by their role in reverse cholesterol transport as well as other functional activities, including significant anti-inflammatory and antioxidant properties. It has been shown that HDL anti-inflammatory and antioxidant functions are defective in metabolically stable diabetic patients; however they have not been evaluated during a hyperglycemic crisis. Aim: to determine the antioxidant activity of HDL during a severe diabetic decompensation and to analyze whether this function is restored after resolution of the acute event. Methods: the antioxidant activity of HDL was measured in vitro by a fluorescent assay in plasma samples obtained from diabetic patients with acute metabolic decompensation at admission, recovery within the hospital and follow-up in ambulatory care. As a comparison, HDL particles from some healthy subjects were used as controls. Results: the HDL antioxidant function was significantly reduced in patients during an acute diabetic decompensation compared with the control group, and was gradually restored reaching normal values during the ambulatory follow-up. Hyperglycemic crisis also showed low plasma paraoxonase-1 activity, which increased significantly during at follow-up. Conclusion: HDL particles isolated from acute diabetic descompensated patients exhibit a significantly and reversibly low antioxidant capacity, which is probably due to a reduced paraoxonase-1 activity (AU)

[ANTIOXIDANT DYSFUNCTIONALITY OF HIGH-DENSITY LIPOPROTEINS (HDL) IN DECOMPENSATED DIABETIC PATIENTS]. / DISFUNCIONALIDAD ANTIOXIDANTE DE LAS LIPOPROTEÍNAS DE ALTA DENSIDAD (HDL) EN PACIENTES DIABÉTICOS DESCOMPENSADOS.

INTRODUCTION: high density lipoproteins (HDL) have important cardiovascular protective effects mediated by their role in reverse cholesterol transport as well as other functional activities, including significant anti-inflammatory and antioxidant properties. It has been shown that HDL anti-inflammatory and antioxidant functions are defective in metabolically stable diabetic patients; however they have not been evaluated during a hyperglycemic crisis. AIM: to determine the antioxidant activity of HDL during a severe diabetic decompensation and to analyze whether this function is restored after resolution of the acute event. METHODS: the antioxidant activity of HDL was measured in vitro by a fluorescent assay in plasma samples obtained from diabetic patients with acute metabolic decompensation at admission, recovery within the hospital and follow-up in ambulatory care. As a comparison, HDL particles from some healthy subjects were used as controls. RESULTS: the HDL antioxidant function was significantly reduced in patients during an acute diabetic decompensation compared with the control group, and was gradually restored reaching normal values during the ambulatory follow-up. Hyperglycemic crisis also showed low plasma paraoxonase-1 activity, which increased significantly during at follow-up. CONCLUSION: HDL particles isolated from acute diabetic descompensated patients exhibit a significantly and reversibly low antioxidant capacity, which is probably due to a reduced paraoxonase-1 activity.

Introducción: las lipoproteínas de alta densidad (HDL) tienen un importante efecto protector cardiovascular mediado por su función durante el transporte reverso del colesterol, así como por otras actividades, incluyendo una significativa acción antiinflamatoria y antioxidante. La funcionalidad antiinflamatoria y antioxidante de las HDL está alterada en los pacientes diabéticos crónicos estables, aunque no existe mayor información en caso de una crisis hiperglicémica. Objetivo: determinar si durante un estado de descompensación diabética aguda las partículas de HDL exhiben un deterioro de su función antioxidante y si esta logra recuperarse una vez resuelto el cuadro agudo. Métodos: la actividad antioxidante de las HDL se midió mediante un ensayo de fluorescencia in vitro en muestras plasmáticas de pacientes diabéticos con descompensación aguda obtenidas tanto al ingreso, alcanzada la resolución intrahospitalaria del evento agudo, así como en un control ambulatorio post-hospitalización. Como comparación, se analizaron partículas de HDL de algunos sujetos sanos como condición control. Resultados: la actividad antioxidante de las HDL en pacientes con descompensación diabética aguda fue significativamente menor a la observada en el grupo control sano, y esta se fue recuperando progresivamente hasta normalizarse en el momento del control ambulatorio. La crisis hiperglicémica también demostró una baja actividad plasmática de la enzima antioxidante paraoxonasa- 1, la cual aumentó significativamente en el control ambulatorio. Conclusión: las partículas de HDL presentes en pacientes con una descompensación diabética aguda presentan una reducción significativa y reversible de su capacidad antioxidante, probablemente como consecuencia de una alteración en la actividad de la paraoxonasa-1.

Cetoacidosis diabética: Casuística 2008-2012, epidemiología y fisiopatología / Treatment of diabetic ketoacidosis using 2009 American Diabetes Association guidelines

Background: During 2009, new guidelines for the treatment of diabetic ketoacidosis were published by the American Diabetes Association. Aim: To assess the impact of new treatment guidelines on the evolution of patients treated for diabetic ketoacidosis (KAD). Patients and Methods: Anonymous data was obtained from computational medical records of patients treated for KAD at our institution two years before (“Traditional Protocol”) and TWO years after (“ADA-2009 Protocol”) the publication of the 2009 American Diabetes Association (ADA) KAD guidelines. Results: Twenty three patients aged 36.5 ± 15.1 years were treated with the traditional method and 23 patients aged 44.4 ± 21.1 years were treated following 2009 ADA guidelines. Among patients treated with the traditional protocol and treated following ADA 2009 guidelines, the diabetes type 1/type 2 ratio was18/5 and 19/16 respectively (p = NS), the glycosylated hemoglobin on admission was 12.6 ± 2.5 and 14.3 ± 2.7% respectively (p = 0.03), minimal blood pH was 7.15 ± 0.14 and 7.19 ± 0.09 respectively (p = NS), bicarbonate was required in seven and no patient respectively (p = 0.01), hypokalemia < 3.5 mEq/L occurred in 78.2 and 48.5% of patients (p = 0.03), the lapse until resolution was 28.7 ± 28.0 and 28.8 ± 20.6 hours (p = NS). Only one patient, treated following ADA 2009 guidelines, died. Conclusions: Introduction of the ADA-2009 protocol for the treatment of KAD resulted in decrease in the use of intravenous bicarbonate and a reduction in the incidence of hypokalemia. There was no impact neither in the lapse until resolution or lethality.

[Treatment of diabetic ketoacidosis using 2009 American Diabetes Association guidelines]. / Cetoacidosis diabética: Casuística 2008-2012, epidemiología y fisiopatología.

BACKGROUND: During 2009, new guidelines for the treatment of diabetic ketoacidosis were published by the American Diabetes Association. AIM: To assess the impact of new treatment guidelines on the evolution of patients treated for diabetic ketoacidosis (KAD). PATIENTS AND METHODS: Anonymous data was obtained from computational medical records of patients treated for KAD at our institution two years before ("Traditional Protocol") and TWO years after ("ADA-2009 Protocol") the publication of the 2009 American Diabetes Association (ADA) KAD guidelines. RESULTS: Twenty three patients aged 36.5 ± 15.1 years were treated with the traditional method and 23 patients aged 44.4 ± 21.1 years were treated following 2009 ADA guidelines. Among patients treated with the traditional protocol and treated following ADA 2009 guidelines, the diabetes type 1/type 2 ratio was 18/5 and 19/16 respectively (p = NS), the glycosylated hemoglobin on admission was 12.6 ± 2.5 and 14.3 ± 2.7% respectively (p = 0.03), minimal blood pH was 7.15 ± 0.14 and 7.19 ± 0.09 respectively (p = NS), bicarbonate was required in seven and no patient respectively (p = 0.01), hypokalemia < 3.5 mEq/L occurred in 78.2 and 48.5% of patients (p = 0.03), the lapse until resolution was 28.7 ± 28.0 and 28.8 ± 20.6 hours (p = NS). Only one patient, treated following ADA 2009 guidelines, died. CONCLUSIONS: Introduction of the ADA-2009 protocol for the treatment of KAD resulted in decrease in the use of intravenous bicarbonate and a reduction in the incidence of hypokalemia. There was no impact neither in the lapse until resolution or lethality.

Profilaxis de enfermedad tromboembólica en pacientes hospitalizados con patología médica, estrechando la brecha entre las guías y la práctica clínica / Strategies for the prophylaxis of thromboembolic disease among medical patients

Thromboembolic disease is the main preventable cause of in-hospital death. Approximately 10 percent of nosocomial deaths are attributable to pulmonary embolism and in most cases, the diagnosis is not suspected before the autopsy. There are cost effective measures to decrease the incidence of thromboembolic disease. Pharmacological prophylaxis decreases the incidence of deep venous thrombosis by 65 percent and the incidence of pulmonary embolism by 35 to 55 percent. Despite this data and the presence of clinical guidelines, prophylaxis of thromboembolic disease is used only in 40 percent of medical patients and in 65 percent of surgical patients with recommended indications. We review the evidence that supports the use of thromboprophylaxis and the different strategies that may increase the compliance of physicians with its use. A protocol implemented in our institution is also proposed.

[Strategies for the prophylaxis of thromboembolic disease among medical patients]. / Profilaxis de enfermedad tromboembólica en pacientes hospitalizados con patología médica, estrechando la brecha entre las guías y la práctica clínica.

Thromboembolic disease is the main preventable cause of in-hospital death. Approximately 10% of nosocomial deaths are attributable to pulmonary embolism and in most cases, the diagnosis is not suspected before the autopsy. There are cost effective measures to decrease the incidence of thromboembolic disease. Pharmacological prophylaxis decreases the incidence of deep venous thrombosis by 65% and the incidence of pulmonary embolism by 35 to 55%. Despite this data and the presence of clinical guidelines, prophylaxis of thromboembolic disease is used only in 40% of medical patients and in 65% of surgical patients with recommended indications. We review the evidence that supports the use of thromboprophylaxis and the different strategies that may increase the compliance of physicians with its use. A protocol implemented in our institution is also proposed.

Hipoglicemia recurrente como causa reversible de síndrome demencial en adultos mayores diabéticos, a propósito de un caso / Cognitive impairment probably related to repeated episodes of hypoglycemia. Report of one case

We report a 78 year-old diabetic woman, treated with gliburide and metformin, consulting in the emergency room for a non fuctuating impairment in consciousness. She had a history of similar episodes in the last two months. A brain CAT scan showed an old putamen lacunar infarction. Noteworthy was the presence of a low glycosilated hemoglobin level of 5.2 percent. Hypoglycemic medications were discontinued and the patient was discharged in good conditions. After six months of follow up, the patient did not have further episodes of impairment of consciousness.

[Cognitive impairment probably related to repeated episodes of hypoglycemia. Report of one case]. / Hipoglicemia recurrente como causa reversible de síndrome demencial en adultos mayores diabéticos, a propósito de un caso.

We report a 78 year-old diabetic woman, treated with gliburide and metformin, consulting in the emergency room for a non fuctuating impairment in consciousness. She had a history of similar episodes in the last two months. A brain CAT scan showed an old putamen lacunar infarction. Noteworthy was the presence of a low glycosilated hemoglobin level of 5.2%. Hypoglycemic medications were discontinued and the patient was discharged in good conditions. After six months of follow up, the patient did not have further episodes of impairment of consciousness.

Optimal length of triple therapy for H pylori eradication in a population with high prevalence of infection in Chile.

AIM: To compare the efficacy of 7-d versus 14-d triple therapy for the treatment of H pylori infection in Chile, with a prevalence of 73% in general population. METHODS: H pylori-infected patients diagnosed by rapid urease test, with non-ulcer dyspepsia or peptic ulcer disease were randomized to receive omeprazole 20 mg bid, amoxicillin 1 g bid, and clarithromycin 500 mg bid for 7 (OAC7) or 14 (OAC14) d. Primary outcome was eradication rate 6 wk after the treatment. Subgroup analysis was carried out considering the eradication rate among patients with or without peptic ulcer disease and eradication rate among smokers or non-smokers. RESULTS: One hundred and thirty-one patients were randomized to OAC7 (n = 69) or OAC14 (n = 62). The overall eradication rate (intention-to-treat) was 78.3% in OAC7 and 85.5% in OAC14 groups, without a significant difference (P =0.37). No significant difference in the eradication rate was found among the patients with peptic ulcer disease (n = 31) between the OAC7 group (85.7%) and OAC14 group (87.5%). However, smokers had an obviously lower eradication rate compared to non-smokers, particularly in the OAC7 group (57.1% in smokers vs 83.6% in non-smokers; P = 0.06). Adverse effects rate were similar between both groups. CONCLUSION: Short-term efficacy of triple therapy with OAC for 7 d is comparable to 14 d in this high-prevalence population. Longer follow-up, and studies focused to some subgroups of patients (smokers and non-ulcer patients) are necessary to support widespread use of 7-d instead of 10-14-d triple therapy in a developing country like Chile.

Role of reactive oxygen species in bradykinin-induced proliferation of vascular smooth muscle cells.

In addition to the induction of cell proliferation and migration, bradykinin (BK) can increase c-fos mRNA expression, activate ERK 1/2 and generate reactive oxygen species (ROS) in vascular smooth muscle cells (VSMC). It is not known, however, whether BK can induce cellular proliferation and extracellular matrix production via redox-sensitive signaling pathways. We investigated the role(s) of ROS in proliferation, migration and collagen synthesis induced by BK in VSMC derived from Sprague Dawley rat aorta. BK (10 nM) increased VSMC proliferation by 30% (n=5); this proliferation was inhibited by the antioxidants N-acetylcysteine (20 mM) and alpha-lipoic acid (LA, 250 mM). In addition, BK induced an increase in cell migration and in collagen levels that were blocked by LA. ROS production induced by BK (n=10) was significantly inhibited by bisindolylmaleimide (4microM) and by PD98059 (40microM). These results suggest that: 1) ROS participate in the mechanism(s) used by bradykinin to induce cellular proliferation; 2) bradykinin induces ROS generation through a pathway that involves the kinases PKC and MEK; and 3) ROS participate in the pathways mediating cell migration and the production of collagen as a response to treatment with bradykinin. To our knowledge, this is the first report describing mechanisms to explain the participation of ROS in the cellular proliferation and extracellular matrix pathway regulated by BK.