Primary HPV-DNA screening in women under 30 years of age: health technology assessment / Tamización primaria con prueba ADN-VPH en mujeres menores de 30 años: evaluación de tecnología sanitaria

Background: Primary screening with Human Papilloma Virus (HPV) testing was introduced in Colombia in 2014 for individuals between 30 and 65 years of age. When the result is positive, cytology triage is performed for colposcopy referral. The convenience of initiating HPV-DNA testing for screening at 25 years of age is currently a subject of discussion. Therefore, the objective of this health technology assessment (HTA) is to analyze the available evidence regarding safety, efficacy, cost-effectiveness, values and preferences, ethical dilemmas and considerations pertaining to the implementation of the HPV-DNA test as a cervical screening strategy in women under 30 years of age in the Colombian context. Domains to be assessed: Clinical efficacy and safety 1. Cumulative rate of cervical intraepithelial neoplasia (CIN) grade 2 or high-er after 2 screening rounds. 2. Cumulative rates of invasive cancer of the uterine cervix after 2 screening rounds. 3. Safety: referral to colposcopy. Cost-effectiveness Cost-effectiveness for Colombia. Other domains considered Ethical considerations associated with cervical screening in women under 30 years of age. Organizational and individual considerations. Barriers and facilitators pertaining to the implementation of cervical screening in women under 30 years of age in the Colombian context. Methods: Clinical efficacy and safety assessment A systematic literature search of systematic reviews and clinical trials was conducted in MEDLINE, Embase and CENTRAL. The body of evidence was rated using the GRADE approach. An interdisciplinary team was then convened to create a working group to review the retrieved evidence. This led to the discussion and construction of the conclusions following the guidelines of a formal consensus in accordance with the RAND/UCLA methodology. Economic study Systematic literature research of studies that had assessed cost-effectiveness for Colombia. Results: Clinical outcomes An integrative analysis of 5 randomized clinical trials that met the inclusion critera was performed. Compared with cytology, primary HPV-DNA testing in women under 30 years of age could be associated with a lower frequency of CIN+2 lesions during the first screening round (RR: 1.57; CI: 1.20 to 2.04; low evidence certainty), and a lower incidence of CIN+2 (RR: 0.67; CI: 0.48 to 0.92; low evidence certainty). Moreover, it is associated with a lower frequency of invasive carcinoma at the end of follow-up (RR: 0.19; CI: 0.07 to 0.53; high evidence certainty). Economic results From the financial point of view, the use of HPVDNA testing plus cytology-based triage starting at 25 years of age is perhaps the most cost-effective option for Colombia (incremental cost-effectiveness ratio, COP 8,820,980 in 2013). Other implications Two studies suggest that barriers to implementation attributable to intermediation, public unrest and geographic considerations could be overcome with the use of new screening technologies or strategies. It is important to consider administration and service provision alternatives in order to overcome some acceptability and access barriers. Any cervical screening program must take into consideration ethical principles of nonmaleficence, beneficence, autonomy and equity. Future studies should focus on analyzing new screening techniques with emphasis on the population under 30 years of age. Conclusions: The use of HPV-DNA testing as a screening strategy in women under 30 years of age is a potentially efficacious and cost-effective intervention for Colombia. Future studies should focus on analyzing new screening technologies, with emphasis on the population under 30 years of age.

Antecedentes: A partir del 2014 en Colombia se incorporó la Tamización primaria con prueba de Virus del Papiloma Humano (VPH) desde los 30 hasta los 65 años, cuando la prueba es positiva se hace triage con citología para remisión a colposcopia. Actualmente se discute la conveniencia de iniciar la tamización con prueba de ADN de VPH a partir de los 25 años. De esta manera, el objetivo de esta evaluación de tecnologías sanitarias es analizar la evidencia disponible en torno a la seguridad, efectividad, costoefectividad, valores y preferencias, dilemas éticos y aspectos relacionados con la implementación para el contexto colombiano de la prueba ADN-VPH como estrategia de tamización cervical en mujeres menores de 30 años. Dominios a evaluar: Eficacia clínica y seguridad 1. Tasa acumulada de neoplasia intraepitelial cervical (NIC) grado 2 o más avanzado luego de 2 rondas de tamización. 2. Tasas acumuladas de cáncer invasor de cérvix luego de 2 rondas de tamización. 3. Seguridad: remisión a colposcopia. Costo-efectividad Costo efectividad para Colombia. Otros dominios considerados Aspectos éticos asociados a la tamización cervical en mujeres menores de 30 años. Aspectos organizacionales y del individuo. Barreras y facilitadores relacionados con la implementación en el contexto colombiano de la tamización cervical en mujeres menores de 30 años. Métodos: Evaluación de efectividad y seguridad clínicas Se realizó una búsqueda sistemática de la literatura en MEDLINE, Embase y CENTRAL de revisiones sistemáticas y ensayos clínicos. Se calificó el cuerpo de la evidencia con la aproximación GRADE. Posteriormente, se convocó a un grupo interdisciplinario a una mesa de trabajo en donde se presentó la evidencia recuperada, dando paso a la discusión y a la construcción de las conclusiones, siguiendo los lineamientos de un consenso formal acorde a la metodología RAND/UCLA. Estudio económico Se hizo una búsqueda sistemática de la literatura de estudios que hubieran evaluado el costo-efectividad para Colombia. Resultados: De 7.659 referencias recuperadas se incluyeron 8 estudios. Resultados clínicos Se realizó un análisis integrativo de 5 ensayos clínicos aleatorizados que cumplieron con los criterios de inclusión. Cuando se compara frente a la citología, la tamización primaria con ADN-VPH en mujeres menores de 30 años, podría asociarse con una mayor frecuencia de detección de lesiones NIC2+ durante la primera ronda de cribado (RR: 1.57; IC: 1,20 a 2,04; certeza en la evidencia baja), con una menor incidencia de NIC2+ (RR:0,67; IC: 0,48 a 0,92; certeza en la evidencia baja) y se asocia con una menor frecuencia de carcinoma invasor al término del seguimiento (RR: 0,19; IC: 0,07 a 0,53; certeza en la evidencia alta). Resultados económicos Desde el punto de vista económico, la alternativa de ADN-VPH y triage con citología desde los 25 años quizás representa la alternativa más costo-efectiva para Colombia (razón costo-efectividad incremental $8.820.980 COP año 2013). Otras implicaciones Dos estudios sugieren que las barreras de implementación, atribuibles a circunstancias de intermediación, de orden público y de carácter geográfico, podrían ser solventadas por nuevas tecnologías o estrategias de cribado. Es importante considerar alternativas de forma de administración y de prestación de servicios para solventar algunas barreras de aceptabilidad y acceso. Todo programa de tamización cervical debe contemplar los principios éticos de no maleficencia, beneficencia, autonomía y equidad. Futuros estudios deben enfocarse en analizar nuevas tecnologías de cribado con énfasis en población menor de 30 años. Conclusiones: El uso de la prueba ADN-VPH como estrategia de tamización en mujeres menores de 30 años es una intervención probablemente efectiva y costoefectiva para Colombia. Futuros estudios deben enfocarse en analizar nuevas tecnologías de cribado con énfasis en población menor de 30 años.

Riesgo de desarrollar LIE-AG en pacientes con tamizaje inicial positivo para VPH y citología cervicovaginal negativa en seguimiento hasta 10 años: revisión sistemática y metaanálisis / Risk of developing H-SIL in patients with initial positive screening for HPV and negative cervicovaginal cytology in follow-up up to 10 years: systematic review and meta-analysis

Resumen Introducción: El cáncer de cérvix es el segundo en frecuencia y el tercero en mortalidad; la infección por el virus del papiloma humano (VPH) está asociada al riesgo de cáncer; sin embargo, no se conoce el riesgo acumulado a 1, 2, 3, 5 y 10 años. Objetivo: Determinar el riesgo de las pacientes VPH positivo con evaluación inicial citológica negativa para desarrollar lesión intraepitelial de alto grado a lo largo del tiempo. Método: Se realizó una revisión sistemática de artículos en inglés y español de los últimos 20 años, usando las bases de datos PubMed, Cochrane, LILACS, ProQuest y Embase. Se incluyeron ensayos clínicos aleatorizados en los que se determinaba el estado VPH y se realizaba seguimiento con citología cervicovaginal a 1, 2, 3, 5 y 10 años en mujeres de 20-64 años. Resultados: Se incluyeron siete ensayos clínicos aleatorizados, con un total de 98.521 mujeres, de ellas 8820 VPH positivo y 89.701 VPH negativo al ingreso, seguidas hasta por 10 años con citología cervicovaginal, encontrando que la infección por VPH es un factor de riesgo para desarrollar lesiones intraepiteliales de alto grado a 2, 5 y 10 años, con un riesgo relativo de 110.94 (79.41-154.97), 83.65 (55.22-126.73) y 29.71 (5.72-154.33), respectivamente. Conclusiones: La infección por VPH es un factor de riesgo importante para el desarrollo de lesiones intraepiteliales de alto grado a 2, 5 y 10 años.

Abstract Introduction: Cervical cancer is the second in frequency and the third in mortality, infection by the human papillomavirus (HPV) is associated with the risk of increased cancer; however, the cumulative risk of 1, 2, 3, 5 and 10 years is not known. Objective: To determine the risk of HPV-positive patients with negative initial cytological evaluation for developing high-grade intraepithelial lesion over time. Method: A systematic review of articles in English and Spanish in the last 20 years was carried out, using the PubMed, Cochrane, LILACS, ProQuest and Embase databases. Randomized clinical trials were included in which HPV was performed and subsequent follow-up with cervicovaginal cytology at 1, 2, 3, 5 and 10 years in women aged 20-64 years. Results: Seven randomized clinical trials were included, a total of 98,521 women, 8820 with positive HPV and 89701 negative on admission and followed up for up to 10 years with cervicovaginal cytology. Finding that HPV infection is a risk factor for developing high-grade intraepithelial lesion at 2, 5 and 10 years with a relative risk of 110.94 (79.41-154.97), 83.65 (55.22- 126.73) and 29.71 (5.72-154.33), respectively. Conclusions: HPV infection is an important risk factor for the development of high-grade intraepithelial lesion at 2, 5 and 10 years.

Diagnostic Accuracy of Rapid Point-of-Care Tests for Detecting Active Syphilis: A Systematic Review and Meta-Analysis.

BACKGROUND: Syphilis represents an important cause of morbidity and mortality. Point-of-care (POC) test offers the advantages of diagnosing the condition and the possibility of starting treatment immediately. METHODS: MEDLINE, Embase, CENTRAL, LILACS, World Health Organization International Clinical Trials Registry Platform, Web of Science, OpenGrey, and DARE were searched without language restrictions from inception to September 30, 2020. Diagnostic test accuracy studies that enrolled men and nonpregnant women of reproductive age under field conditions were analyzed. Only studies wherein all the patients had undergone a rapid POC test and those that included the reference standard (treponemal plus nontreponemal test) were eligible for inclusion. Studies were independently assessed for inclusion, data extraction, and bias risk. The data from these studies were extracted for meta-analyses. The quality of the evidence was assessed using the GRADE approach. Registration Prospero CRD42018107532. RESULTS: Nine studies with 9666 participants were included. Nine POC brands were assessed. Sensitivities of the tests ranged from 0.67 to 1.00 and specificities from 0.93 to 1.00. The mean sensitivity and specificity of all the included studies was 0.86 (95% confidence interval, 0.79-0.91) and 0.98 (95% confidence interval, 0.96-0.99), respectively. CONCLUSIONS: Based on the results of this systematic review, the POC test for syphilis showed good sensitivity and excellent specificity.

Expectant Versus Interventionist Care in the Management of Severe Preeclampsia Remote from Term: A Systematic Review.

OBJECTIVE: To compare the effects of expectant versus interventionist care in the management of pregnant women with severe preeclampsia remote from term. DATA SOURCES: An electronic search was conducted in the Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (EMBASE), Cochrane Central Register of Controlled Trials (CENTRAL), Latin American and Caribbean Health Sciences Literature (LILACS, for its Spanish acronym), World Health Organization's International Clinical Trials Registry Platform (WHO-ICTRP), and OpenGrey databases. The International Federation of Gynecology and Obstetrics (FIGO, for its French acronym), Royal College of Obstetricians and Gynaecologists (RCOG), American College of Obstetricians and Gynecologists (ACOG), and Colombian Journal of Obstetrics and Gynecology (CJOG) websites were searched for conference proceedings, without language restrictions, up to March 25, 2020. SELECTION OF STUDIES: Randomized clinical trials (RCTs), and non-randomized controlled studies (NRSs) were included. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to evaluate the quality of the evidence. DATA COLLECTION: Studies were independently assessed for inclusion criteria, data extraction, and risk of bias. Disagreements were resolved by consensus. DATA SYNTHESIS: Four RCTs and six NRS were included. Low-quality evidence from the RCTs showed that expectant care may result in a lower incidence of appearance, pulse, grimace, activity, and respiration (Apgar) scores < 7 at 5 minutes (risk ratio [RR]: 0.48; 95% confidence interval [95%CI]: 0.23%to 0.99) and a higher average birth weight (mean difference [MD]: 254.7 g; 95%CI: 98.5 g to 410.9 g). Very low quality evidence from the NRSs suggested that expectant care might decrease the rates of neonatal death (RR: 0.42; 95%CI 0.22 to 0.80), hyaline membrane disease (RR: 0.59; 95%CI: 0.40 to 0.87), and admission to neonatal care (RR: 0.73; 95%CI: 0.54 to 0.99). No maternal or fetal differences were found for other perinatal outcomes. CONCLUSION: Compared with interventionist management, expectant care may improve neonatal outcomes without increasing maternal morbidity and mortality.

OBJETIVO: Comparar os efeitos dos cuidados expectantes versus intervencionistas no manejo de gestantes com pré-eclâmpsia grave distante do termo. FONTES DE DADOS: Foi realizada uma busca eletrônica no Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (EMBASE), Cochrane Central Register of Controlled Trials (CENTRAL), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS, para o espanhol) acrônimo), Plataforma Internacional de Registro de Ensaios Clínicos da Organização Mundial da Saúde (OMS-ICTRP) e bancos de dados OpenGrey. Foram pesquisados os sites da Federação Internacional de Ginecologia e Obstetrícia (FIGO, por sua sigla em francês), do Royal College of Obstetricians e Ginecologistas (RCOG), do American College of Obstetricians e Ginecologistas (ACOG) e do Colombian Journal of Obstetrics and Gynecology (CJOG) procedimentos da conferência, sem restrições de idioma, até 25 de março de 2020. SELEçãO DE ESTUDOS: Ensaios clínicos randomizados (RCTs) e estudos controlados não randomizados (NRSs) foram incluídos. A abordagem de Classificação de Recomendações, Avaliação, Desenvolvimento e Avaliação (GRADE) foi usada para avaliar a qualidade da evidência. COLETA DE DADOS: Os estudos foram avaliados de forma independente quanto aos critérios de inclusão, extração de dados e risco de viés. As discordâncias foram resolvidas por consenso. SíNTESE DE DADOS: Quatro RCTs e seis NRS foram incluídos. Evidências de baixa qualidade dos ECRs mostraram que o cuidado expectante pode resultar em uma incidência menor de pontuações de aparência, pulso, careta, atividade e respiração (Apgar) <7 em 5 minutos (razão de risco [RR]: 0,48; intervalo de confiança de 95% [IC 95%]: 0,23% a 0,99) e um peso médio ao nascer superior (diferença média [MD]: 254,7 g; IC 95%: 98,5 ga 410,9 g). Evidências de qualidade muito baixa dos NRSs sugeriram que os cuidados expectantes podem diminuir as taxas de morte neonatal (RR: 0,42; IC de 95% 0,22 a 0,80), doença da membrana hialina (RR: 0,59; IC de 95%: 0,40 a 0,87) e admissão à assistência neonatal (RR: 0,73; IC 95%: 0,54 a 0,99). Nenhuma diferença materna ou fetal foi encontrada para outros resultados perinatais. CONCLUSãO: Em comparação com o manejo intervencionista, o cuidado expectante pode melhorar os resultados neonatais sem aumentar a morbidade e mortalidade materna.

Expectant Versus Interventionist Care in the Management of Severe Preeclampsia Remote from Term: A Systematic Review / Cuidado expectante versus cuidado intervencionista no tratamento da pré-eclâmpsia grave a distância: uma revisão sistemática

Abstract Objective To compare the effects of expectant versus interventionist care in the management of pregnant women with severe preeclampsia remote from term. Data sources An electronic search was conducted in the Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (EMBASE), Cochrane Central Register of Controlled Trials (CENTRAL), Latin American and Caribbean Health Sciences Literature (LILACS, for its Spanish acronym), World Health Organization's International Clinical Trials Registry Platform (WHO-ICTRP), and Open- Grey databases. The International Federation of Gynecology and Obstetrics (FIGO, for its French acronym), Royal College of Obstetricians and Gynaecologists (RCOG), American College of Obstetricians and Gynecologists (ACOG), and Colombian Journal of Obstetrics and Gynecology (CJOG) websites were searched for conference proceedings, without language restrictions, up to March 25, 2020. Selection of studies Randomized clinical trials (RCTs), and non-randomized controlled studies (NRSs) were included. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to evaluate the quality of the evidence. Data collection Studies were independently assessed for inclusion criteria, data extraction, and risk of bias. Disagreements were resolved by consensus. Data synthesis Four RCTs and six NRS were included. Low-quality evidence from the RCTs showed that expectant care may result in a lower incidence of appearance, pulse, grimace, activity, and respiration (Apgar) scores<7 at 5 minutes (risk ratio [RR]: 0.48; 95% confidence interval [95%CI]: 0.23%to 0.99) and a higher average birth weight (mean difference [MD]: 254.7 g; 95%CI: 98.5 g to 410.9 g). Very low quality evidence from the NRSs suggested that expectant care might decrease the rates of neonatal death (RR: 0.42; 95%CI 0.22 to 0.80), hyalinemembrane disease (RR: 0.59; 95%CI: 0.40 to 0.87), and admission to neonatal care (RR: 0.73; 95%CI: 0.54 to 0.99). Nomaternal or fetal differences were found for other perinatal outcomes. Conclusion Compared with interventionist management, expectant care may improve neonatal outcomes without increasing maternal morbidity and mortality.

Resumo Objetivo Comparar os efeitos dos cuidados expectantes versus intervencionistas no manejo de gestantes com pré-eclâmpsia grave distante do termo. Fontes de dados Foi realizada uma busca eletrônica no Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (EMBASE), Cochrane Central Register of Controlled Trials (CENTRAL), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS, para o espanhol) acrônimo), Plataforma Internacional de Registro de Ensaios Clínicos da Organização Mundial da Saúde (OMS-ICTRP) e bancos de dados OpenGrey. Foram pesquisados os sites da Federação Internacional de Ginecologia e Obstetrícia (FIGO, por sua sigla em francês), do Royal College of Obstetricians e Ginecologistas (RCOG), do American College of Obstetricians e Ginecologistas (ACOG) e do Colombian Journal of Obstetrics and Gynecology (CJOG) procedimentos da conferência, sem restrições de idioma, até 25 de março de 2020. Seleção de estudos Ensaios clínicos randomizados (RCTs) e estudos controlados não randomizados (NRSs) foram incluídos. A abordagem de Classificação de Recomendações, Avaliação, Desenvolvimento e Avaliação (GRADE) foi usada para avaliar a qualidade da evidência. Coleta de dados Os estudos foram avaliados de forma independente quanto aos critérios de inclusão, extração de dados e risco de viés. As discordâncias foram resolvidas por consenso. Síntese de dados Quatro RCTs e seis NRS foram incluídos. Evidências de baixa qualidade dos ECRs mostraram que o cuidado expectante pode resultar em uma incidência menor de pontuações de aparência, pulso, careta, atividade e respiração (Apgar) <7 em 5 minutos (razão de risco [RR]: 0,48; intervalo de confiança de 95% [IC 95%]: 0,23% a 0,99) e um peso médio ao nascer superior (diferença média [MD]: 254,7 g; IC 95%: 98,5 ga 410,9 g). Evidências de qualidade muito baixa dos NRSs sugeriram que os cuidados expectantes podem diminuir as taxas de morte neonatal (RR: 0,42; IC de 95% 0,22 a 0,80), doença da membrana hialina (RR: 0,59; IC de 95%: 0,40 a 0,87) e admissão à assistência neonatal (RR: 0,73; IC 95%: 0,54 a 0,99). Nenhuma diferença materna ou fetal foi encontrada para outros resultados perinatais. Conclusão Em comparação com o manejo intervencionista, o cuidado expectante pode melhorar os resultados neonatais sem aumentar a morbidade e mortalidade materna.

Use of non-pharmacological interventions during urinary catheter insertion for reducing urinary tract infections in non-immunocompromised adults. A systematic review / intervenciones no farmacológicas durante la inserción de un catéter urinario permanente para reducir las infecciones en adultos inmunocompetentes. Revisión sistemática

Abstract Introduction: Catheter-associated urinary tract infections (CAUTI) account for up to 30% of hospital -acquired infections. In this regard, several studies have reported the use of non-pharmacological interventions during urinary catheter insertion aimed at reducing the occurrence rate of CAUTI. Objective: To assess the safety and effectiveness of non-pharmacological interventions during urinary catheter insertion aimed at reducing the risk of contracting infections in non-immunocompromised adults. Materials and methods: A literature review was conducted in the MEDLINE, Embase, and LILACS databases. Only randomized clinical trials comparing the use of non-pharmacological interventions to placebos, pharmacological interventions, or no intervention during catheter insertion were included. Results: Eight studies were retrieved (8 718 participants). Based on the evidence found in the review (low-quality and very low-quality evidence according to the GRADE system), using non-pharmacological interventions reduces the frequency of asymptomatic bacteriuria episodes (RR 0.67, 95%CI 0.48-0.94; 7 studies) or mild adverse events (RR 0.84, 95%CI 0.74-0.96; 2 studies), but does not reduce the occurrence rate of symptomatic urinary tract infections (RR 0.90, 95%CI 0.61-1.35; 4 studies) or improves quality-of-life scores (MD -0.01 EQ-5D scale; 95%CI (-0.03)-(0.01), 1 study). Conclusion: The use of non-pharmacological interventions during urinary catheter insertion does not pose any risk at all. Instead, it could help reduce the occurrence rate of infections associated with this procedure, such as asymptomatic bacteriuria and mild adverse events. However, there is very little evidence (in fact, low and very low-quality evidence) to make conclusions on the effectiveness of these interventions.

Resumen Introducción. La infección asociada al catéter urinario es responsable de hasta un 30% de las infecciones nosocomiales. Al respecto, se ha descrito el uso de intervenciones no farmacológicas durante la inserción del catéter urinario para reducir la frecuencia de infecciones asociadas. Objetivo. Evaluar la seguridad y la efectividad de intervenciones no farmacológicas durante la inserción del catéter urinario diseñadas para reducir el riesgo de infección en adultos inmunocompetentes. Materiales y métodos. Se realizó una búsqueda en las bases de datos MEDLINE, Embase y LILACS. Se incluyeron ensayos clínicos aleatorizados que compararan el uso de intervenciones no farmacológicas con el uso de placebos, el uso de intervenciones farmacológicas o la ausencia de intervención durante la inserción del catéter. Resultados. Se encontraron ocho estudios (8 718 participantes). Con base en la evidencia encontrada (baja y muy baja calidad según la clasificación del sistema GRADE), el uso de intervenciones no farmacológica reduce la frecuencia de bacteriuria asintomática (RR 0.67; IC95%: 0.48-0.94; 7 estudios) o de eventos adversos menores (RR 0.84, IC95%: 0.74-0.96; 2 estudios), pero no disminuye la tasa de infecciones sintomáticas del tracto urinario (RR 0.90; IC95%: 0.61 a 1.35; 4 estudios), ni mejora las puntuaciones de calidad de vida (escala MD -0.01 EQ-5D, IC95%: (-0.03)-(0.01), 1 estudio). Conclusión. El uso de intervenciones no farmacológicas durante la inserción del catéter urinario no supone riesgo alguno y sí podría ayudar a disminuir la frecuencia infecciones asociadas a este procedimiento, tales como la bacteriuria asintomática y eventos adversos menores; sin embargo, hay poca evidencia, y de baja o muy baja calidad, para llegar a conclusiones sobre su efectividad.

Evaluation of inter-observer concordance of the Swede score for digital colposcopic images / Evaluación de la concordancia interobservador de la escala Swede para imágenes colposcópicas digitales

Objective: To assess inter-observer concordance by training level when applying the Swede score to digital colposcopy images. Materials and methods: Concordance study assembled in a cross-sectional study. The population consisted of patients referred for colposcopy to a cervical pathology reference center in Bogotá, Colombia, due to abnormal cytology. Convenience sampling was used. Measured variables were age, level of education, marital status, risk factors for cervical cancer such as parity, age of sexual activity initiation and number of sexual contacts, contraceptive method, cytology report and colposcopy result according to the criteria of the Swede score. Concordance was calculated using the weighted kappa (k) index. Results: The analysis was based on a set of 3 digital colposcopic images of 251patients. For the total score on the scale, low agreement (k = 0.38; 95% CI: 0.26-0.44) was found between two expert gynecologists; low agreement (k = 0.27; IC 95 %: 0.20-0.38) was also shown for a pair of gynecologists with different training levels, while moderate agreement (k = 0.45; 95% CI: 0.34-0.53) was found for the third pair. For individual criteria on the Swede scale, the best agreement was found for "acetowhite reaction" and "lesion size" (k = 0.43; 95% CI: 0.33-0.53). Conclusions: Inter-observer concordance using the Swede score for digital colposcopic images ranged from low to moderate according to the level of training of the gynecologists.

Objetivo: evaluar la concordancia interobservador por nivel de entrenamiento al aplicar la escala Swede utilizando imágenes digitales de colposcopias. Materiales y métodos: estudio de concordancia ensamblado en un estudio de corte transversal. Se incluyeron pacientes remitidas para colposcopia por resultado de citología anormal, en un centro de referencia de patología cervical de Bogotá, Colombia. Muestreo por conveniencia. Variables medidas: edad, grado de escolaridad, estado civil, factores de riesgo para cáncer de cérvix (paridad, edad de inicio de la vida sexual, número de contactos sexuales); método de planificación, reporte de la citología y resultado de la colposcopia de acuerdo con los criterios de la escala Swede. Se utilizó estadística descriptiva, la concordancia se calculó usando el estadístico kappa (k) ponderado. Resultados: el análisis se realizó con un set de 3 imágenes colposcópicas digitales de 251 pacientes. Para el puntaje total de la escala, dos ginecólogos expertos mostraron una concordancia baja (k= 0,38; IC 95 %: 0,26-0,44), una pareja de dos ginecólogos con diferente nivel de entrenamiento mostró una concordancia baja (k = 0,27; IC 95 %: 0,20-0,38) y el otro par mostró una concordancia moderada (k= 0,45; IC 95 %: 0,34-0,53). Para los criterios individuales de la escala Swede la mejor concordancia se dio para "reacción acetoblanca" y "tamaño de la lesión" (k= 0,43; IC 95 %: 0,33-0,53). Conclusiones: la concordancia interobservador utilizando la escala Swede en imágenes colposcópicas digitales varió de baja a moderada según el nivel de entrenamiento de los ginecólogos.

Evaluation of inter-observer concordance of the Swede score for digital colposcopic images / Evaluación de la concordancia interobservador de la escala swede para imágenes colposcópicas digitales

RESUMEN Objetivo: evaluar la concordancia interobservador por nivel de entrenamiento al aplicar la escala Swede utilizando imágenes digitales de colposcopias. Materiales y métodos: estudio de concordancia ensamblado en un estudio de corte transversal. Se incluyeron pacientes remitidas para colposcopia por resultado de citología anormal, en un centro de referencia de patología cervical de Bogotá, Colombia. Muestreo por conveniencia. Variables medidas: edad, grado de escolaridad, estado civil, factores de riesgo para cáncer de cérvix (paridad, edad de inicio de la vida sexual, número de contactos sexuales); método de planificación, reporte de la citología y resultado de la colposcopia de acuerdo con los criterios de la escala Swede. Se utilizó estadística descriptiva, la concordancia se calculó usando el estadístico kappa (k) ponderado. Resultados: el análisis se realizó con un set de 3 imágenes colposcópicas digitales de 251 pacientes. Para el puntaje total de la escala, dos ginecólogos expertos mostraron una concordancia baja (k= 0,38; IC 95 %: 0,26-0,44), una pareja de dos ginecólogos con diferente nivel de entrenamiento mostró una concordancia baja (k = 0,27; IC 95 %: 0,20-0,38) y el otro par mostró una concordancia moderada (k= 0,45; IC 95 %: 0,34-0,53). Para los criterios individuales de la escala Swede la mejor concordancia se dio para "reacción acetoblanca" y "tamaño de la lesión" (k= 0,43; IC 95 %: 0,33-0,53). Conclusiones: la concordancia interobservador utilizando la escala Swede en imágenes colposcópicas digitales varió de baja a moderada según el nivel de entrenamiento de los ginecólogos.

Objective: To assess inter-observer concordance by training level when applying the Swede score to digital colposcopy images. Materials and methods: Concordance study assembled in a cross-sectional study. The population consisted of patients referred for colposcopy to a cervical pathology reference center in Bogotá, Colombia, due to abnormal cytology. Convenience sampling was used. Measured variables were age, level of education, marital status, risk factors for cervical cancer such as parity, age of sexual activity initiation and number of sexual contacts, contraceptive method, cytology report and colposcopy result according to the criteria of the Swede score. Concordance was calculated using the weighted kappa (k) index. Results: The analysis was based on a set of 3 digital colposcopic images of 251patients. For the total score on the scale, low agreement (k = 0.38; 95% CI: 0.26-0.44) was found between two expert gynecologists; low agreement (k = 0.27; IC 95 %: 0.20-0.38) was also shown for a pair of gynecologists with different training levels, while moderate agreement (k = 0.45; 95% CI: 0.34-0.53) was found for the third pair. For individual criteria on the Swede scale, the best agreement was found for "acetowhite reaction" and "lesion size" (k = 0.43; 95% CI: 0.33-0.53). Conclusions: Inter-observer concordance using the Swede score for digital colposcopic images ranged from low to moderate according to the level of training of the gynecologists.

Evaluation of the usefulness of a device for Human Papilloma Virus DNA collection and reservation in self-collected cervicovaginal samples stored dry in women with cervical dysplasia, Bogotá, Colombia / Evaluación de la utilidad de un dispositivo para toma y preservación del ADN del virus del papiloma humano de muestras cérvico-vaginales autorrecolectadas y almacenadas en seco en mujeres con displasia cervical, Bogotá, Colombia

ABSTRACT Objective: To evaluate the usefulness of a device for collecting and preserving human papilloma virus (HPV) DNA in self-collected vaginal samples stored dry during 14 days. Materials and methods: Diagnostic concordance pilot study that included non-pregnant women over 25 years of age with a biopsy-confirmed result of cervical intraepithelial neoplasia (CIN) grade 1 or more, coming to two referral centres in Bogotá, Colombia. Women with a history of total hysterectomy were excluded. Convenience sampling was used. The device uses real-time PCR (polymerase chain reaction) for DNA detection. Sociodemographic and clinical variables were measured, as well as the results of the test when the sample was collected by the patient and when it was collected by the physician, and the amount of DNA in the samples taken and processed on day 1, and in those processed on day 14, using Ct thresholds. Descriptive statistics were applied. Overall concordance was estimated by means of the kappa coefficient and mean differences in DNA amount. Materials and methods: Diagnostic concordance pilot study that included non-pregnant women over 25 years of age with a biopsy-confirmed result of cervical intraepithelial neoplasia (CIN) grade 1 or more, coming to two referral centres in Bogotá, Colombia. Women with a history of total hysterectomy were excluded. Convenience sampling was used. The device uses real-time PCR (polymerase chain reaction) for DNA detection. Sociodemographic and clinical variables were measured, as well as the results of the test when the sample was collected by the patient and when it was collected by the physician, and the amount of DNA in the samples taken and processed on day 1, and in those processed on day 14, using Ct thresholds. Descriptive statistics were applied. Overall concordance was estimated by means of the kappa coefficient and mean differences in DNA amount. Results: A kappa coefficient of 0.84 (95% CI: 0.71-0.96) was found for concordance in high-risk HPV detection between the self-collected cervicovaginal sample and the sample taken by the clinician. There were no differences in terms of the amount of viral DNA between day 1 and day 14 (DM -0.34 cycles; 95% CI: - 2.29 to 1.61). Conclusion: Self-collected vaginal samples using the storage device are reliable for high-risk HPV detection in patients with cervical dysplasia, and preserve viral DNA for 14 days if stored dry at room temperature. Confirmation studies in the general population are required.

RESUMEN Objetivo: Evaluar la utilidad de un dispositivo para toma y preservación del DNA del virus del papiloma humano (VPH) de muestras vaginales recolectadas por autotoma y almacenadas en seco durante 14 días. Materiales y métodos: Estudio piloto de concordancia diagnóstica. Se incluyeron mujeres mayores de 24 años no gestantes con un resultado de neoplasia intraepitelial cervical (NIC) grado 1 o más, confirmado por biopsia en dos instituciones de referencia en Bogotá, Colombia. Se excluyeron mujeres con antecedente de histerectomía total. Se realizó un muestreo por conveniencia. El dispositivo utiliza PCR (reacción en cadena de la polimerasa) en tiempo real para detección del ADN. Se midieron variables sociodemográficas y clínicas, así como el resultado de la prueba por autotoma y tomada por el médico, y la cantidad de ADN de las muestras tomadas el día 1 procesadas ese día, y el día 14, por medio del Ct umbral. Se realizó estadística descriptiva. Se calculó la concordancia global por medio del índice de kappa ponderado y la diferencia de medias de la cantidad de ADN. Resultados: La concordancia en la detección de VPH de alto riesgo mostró un kappa = 0,84 (IC 95 %: 0,71-0,96) entre la muestra cervicovaginal recolectada por autotoma frente a la muestra cervical recolectada por el médico. No hubo diferencias en la cantidad de ADN viral entre el día 1 y el 14 (DM -0,34 ciclos; IC 95 %: -2,29 a 1,61). Conclusión: Las muestras vaginales recolectadas por autotoma usando el dispositivo de almacenamiento son confiables para la detección de VPH de alto riesgo en pacientes con displasia cervical, y preservan el ADN viral por 14 días si se almacenan en seco a temperatura ambiente. Se requieren estudios en población general para poder confirmar.

Systematic review of prostaglandin analogues for retained placenta.

BACKGROUND: Medical management of retained placenta could be a safe alternative to manual removal. OBJECTIVE: To evaluate the efficacy of prostaglandin analogues for retained placenta. SEARCH STRATEGY: MEDLINE, EMBASE, CENTRAL, ICTRP, LILACS, and OpenSIGLE were searched without language restrictions from inception to January 31, 2017, by combining terms for retained placenta and prostaglandin analogues. SELECTION CRITERIA: Randomized controlled trials comparing prostaglandin analogues with any other intervention. DATA COLLECTION AND ANALYSIS: Trials were independently assessed for inclusion, data extraction, and risk of bias. Data were extracted for meta-analyses. GRADE was used to evaluate the quality of data. MAIN RESULTS: Seven randomized controlled trials (851 patients) were included. Prostaglandins did not increase the placenta expulsion rate (relative risk [RR] 1.40, 95% confidence interval [CI] 0.83-2.36) or decrease maternal transfusion (RR 0.72, 95% CI 0.43-1.22). In comparison with oxytocin, prostaglandins did not modify the expulsion rate (RR 1.26, 95% CI 0.90-1.78), maternal transfusion (RR 1.05, 95% CI 0.27-4.09), or time for delivery of placenta (mean difference -1.56 minutes, 95% CI, -9.25-6.13). Three trials comparing prostaglandins with oxytocin agonists, ergometrine, and manual removal reported similar results. CONCLUSIONS: Prostaglandin analogues do not offer an effective alternative for management of retained placenta.

Guía de práctica clínica para la administración de sedación fuera del quirófano en pacientes mayores de 12 años / Clinical practice guideline for the management of sedation outside of operating room in patients over 12 years ,

Abstract Introduction: Sedation is a practice frequently used in multiple settings outside the operating room. Currently, it is employed by different interdisciplinary groups. It is imperative to ensure safe, standardized practices and proper training of the personnel involved. Objectives: To update available information, create minimum standards of care for performing high-quality sedation procedures based on the best available evidence. These standards lead to safe and effective care practices, reducing unjustified variability. Materials and methods: A group of different health professionals with experience in sedation outside the operating room and representatives of scientific and patient societies developed the guideline. Through a non-formal consensus of thematic and methodological experts, the content, scope and objectives, study populations, and questions to be examined were all defined. A systematic review of the literature was performed to formulate the recommendations with graduated levels of evidence in accordance with GRADE methodology. Results: A summarized version of the Clinical Practice Guideline with recommendations for the administration of sedation as part of diagnostic or therapeutic procedures outside the operating room in patients over the age of 12. Conclusions: The Clinical Practice Guideline presents evidence-based recommendations in order to standardize the procedure, improving the quality of care, and reducing morbidity of patients that require sedation outside of the operating room.

Resumen Introducción: La sedación es una práctica frecuentemente utilizada en múltiples escenarios fuera de salas de cirugía y que actualmente se realiza por diferentes grupos interdisciplinarios; es perentorio la adquisición de prácticas seguras, estandarizadas y un entrenamiento adecuado del personal involucrado. Objetivos: Actualizar la información disponible, generar estándares mínimos de atención para realizar procedimientos de sedación de alta calidad basada en la mejor evidencia disponible que redunde en prácticas de atención seguras y efectivas, disminuyendo la variabilidad no justificada de la misma. Materiales y métodos: Se conformó un grupo con diferentes profesionales de la salud con experiencia en sedación fuera de quirófano y representantes de sociedades científicas y de pacientes que desarrollaron la guía. A través de un consenso no formal de expertos temáticos y metodólogos, se definió su contenido, alcances y objetivos, población, preguntas a desarrollar y se realizó una revisión sistemática de la literatura para formular las recomendaciones con niveles de evidencia graduados de acuerdo a la metodología GRADE. Resultados: Se presenta una versión resumida de la Guía de Práctica Clínica con recomendaciones para la administración de sedación como parte de los procedimientos diagnósticos o terapéuticos fuera del quirófano en pacientes mayores de 12 años. Conclusiones: La Guía de Práctica Clínica presenta recomendaciones basadas en la evidencia con el propósito de estandarizar el procedimiento, mejorarla calidad de atención y disminuir la morbilidad de los pacientes que requieran sedación fuera del quirófano.

Currículo para la administración de sedación fuera del quirófano en pacientes mayores de 12 años / Curriculum for the administration of sedation outside the operating room in patients over 12 years of age ,

Abstract Introduction: The "Curriculum for the administration of sedation outside the OR in patients over 12 years of age" was developed by the Universidad Nacional de Colombia, by invitation of the Colombian Society of Anesthesiology and Resuscitation - S.C.A.R.E. Objective: Identify the essential knowledge and the skills required by practitioners for the safe and effective administration of sedation to develop of a curriculum for the administration of sedation outside the operating room in patients over 12 years of age. Materials and methods: The curriculum was developed based on the methodological guiding principles of the Clinical Practice Guidelines for the administration of sedation outside the OR, using the PICO approach, in addition to the recommendations according to levels of evidence under the GRADE methodology. Results: The Curriculum was designed with ten (10) recommendations about the competencies that the professional administering sedation to patients older than 12 years of age must have, for diagnostic or therapeutic procedures outside the OR. Conclusions: The Curriculum collects the best available evidence with a view to determine the competencies that the professional administering sedation to patients older than 12 years old shall develop, for diagnostic or therapeutic procedures outside the OR, and hence to contribute to improved quality, reducing the variability and morbidity of patients requiring sedation outside the OR.

Resumen Introducción: El «Currículo para 1a administración de sedación fuera del quirófano en pacientes mayores de 12 años¼ fue desarrollado por la Universidad Nacional de Colombia por convocatoria de la Sociedad Colombiana de Anestesia y Reanimación (S.C.A.R.E.). Objetivo: Identificar los conocimientos indispensables y las competencias necesarias en los profesionales proveedores para que administren sedación de manera segura y efectiva para el desarrollo de un currículo para la administración de sedación fuera del quirófano en pacientes mayores de 12 años. Materiales y métodos: La construcción del Currículo se basó en los lineamientos metodológicos de la Guía Práctica Clínica para la administración de sedación fuera del quirófano en pacientes mayores de 12 años (publicada en este número), en los resultados de la búsqueda sistemática de la literatura orientada por la pregunta PICO y en la formulación de recomendaciones según niveles de evidencia graduados bajo la metodología GRADE. Resultados: Se desarrolló el Currículo con 10 recomendaciones de las competencias que debe tener el profesional que administra sedación a los pacientes mayores de 12 años para procedimientos diagnósticos o terapéuticos fuera del quirófano. Conclusiones: El Currículo recoge la mejor evidencia disponible, con el propósito de determinar las competencias que debe desarrollar el profesional que administra sedación a los pacientes mayores de 12 anos sometidos a procedimientos diagnósticos o terapéuticos fuera del quirófano, y así contribuir a mejorar la calidad, disminuir la variabilidad y la morbilidad de los pacientes que requieran sedación fuera del quirófano.

Antibiotic treatment for the sexual partners of women with bacterial vaginosis.

BACKGROUND: Bacterial vaginosis (BV) is an infection that has a prevalence between 10% to 50% worlwide. BV results in an imbalance of the normal vaginal flora. Microorganisms associated with BV have been isolated from the normal flora of the male genital tract, and their presence could be related to the recurrence of BV after antibiotic treatment. Therefore, the treatment of sexual partners could decrease the recurrence of infection and possibly the burden of the disease. OBJECTIVES: To assess the effectiveness in women and the safety in men of concurrent antibiotic treatment for the sexual partners of women treated for BV. SEARCH METHODS: We searched the Cochrane Sexually Transmitted Infections Group Specialized Register (23 July 2016), CENTRAL (1991 to 23 July 2016), MEDLINE (1946 to 23 July 2016), Embase (1974 to 23 July 2016), LILACS (1982 to 23 July 2016), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (23 July 2016), ClinicalTrials.gov (23 July 2016) and the Web of Science™ (2001 to 23 July 2016). We also handsearched conference proceedings, contacted trial authors and reviewed the reference lists of retrieved studies. SELECTION CRITERIA: Randomized controlled trials (RCTs) that compared the concurrent use of any antibiotic treatment with placebo, no intervention or any other intervention by the sexual partners of women treated for BV. DATA COLLECTION AND ANALYSIS: Three review authors independently assessed trials for inclusion, extracted data and assessed the risk of bias in the included studies. We resolved any disagreements through consensus. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS: Seven RCTs (1026 participants) met our inclusion criteria, and pharmaceutical industry funded four of these trials. Five trials (854 patients) compared any antibiotic treatment of sexual partners with placebo. Based on high quality evidence, antibiotic treatment does not increase the rate of clinical or symptomatic improvement in women during the first week (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.96 to 1.03; 712 participants, four studies; RR 1.06, 95% CI 1.00 to 1.12; 577 patients, three studies, respectively), between the first and fourth week (RR 1.02, 95% CI 0.94 to 1.11; 590 participants, three studies; RR 0.93, 95% CI 0.84 to 1.03; 444 participants, two studies; respectively) or after the fourth week (RR 0.98, 95% CI 0.90 to 1.07; 572 participants, four studies; RR 1.03, 95% CI 0.90 to 1.17; 296 participants, two studies; respectively). Antibiotic treatment does not led to a lower recurrence during the first and fourth week (RR 1.28, 95% CI 0.68 to 2.43; 218 participants, one study; low quality evidence) or after the fourth week of treatment (RR 1.00, 95% CI 0.67 to 1.52; 372 participants, three studies; low quality evidence) in women, but increases the frequency of adverse events (most frequently gastrointestinal symptoms) reported by sexual partners (RR 2.55, 95% CI 1.55 to 4.18; 477 participants, three studies; low quality evidence). Two trials (172 participants) compared any antibiotic treatment for sexual partners with no intervention. When we compared it with no intervention, the effects of antibiotic treatment on recurrence rate after the fourth week (RR 1.71, 95% CI 0.65 to 4.55; 51 participants, one study), clinical improvement between the first and fourth week (RR 0.93, 95% CI 0.70 to 1.25; 152 participants, two studies) and symptomatic improvement after the fourth week (RR 0.66, 95% CI 0.39 to 1.11; 70 participants, one study) were imprecise and there were no differences between groups. We downgraded the quality of the evidence to low or very low. AUTHORS' CONCLUSIONS: High quality evidence shows that antibiotic treatment for sexual partners of women with BV, compared with placebo, does not increase the rate of clinical or symptomatic improvement during the first, between the first and fourth or after the fourth week into the women. Low quality evidence suggests that antibiotic treatment does not led to a lower recurrence rate during the first and fourth or after the fourth week of treatment into the women, but increases the frequency of adverse events reported by sexual partners. Finally, compared with no intervention, antibiotic treatment does not decrease the recurrence rate after the fourth week and does not increase the frequency of clinical or symptomatic improvement between the first and fourth or after the fourth week into the women, respectively.

Aprendiendo sobre determinantes sociales de la salud a través de crónicas, mediante un ambiente virtual de aprendizaje / Learning about social determinants of health through chronicles, using a virtual learning environment

RESUMEN Objetivo Describir la contribución de una estrategia pedagógica basada en construcción de crónicas mediante un Ambiente Virtual de Aprendizaje en la formación en determinantes sociales de la salud en estudiantes de medicina de la Universidad de La Sabana, Metodología Estudio descriptivo con enfoque cualitativo y diseño e implementación de un Ambiente Virtual de Aprendizaje basado en el modelo instruccional ADDIE. Resultados Se implementó un Ambiente Virtual de Aprendizaje con un diseño instruccional basado en las 5 fases del modelo ADDIE, fundamentado en el aprendizaje significativo y en la corriente social constructivista, mediante la estrategia pedagógica de la narrativa de crónicas o historias de vida. Durante el curso se abordaron los determinantes estructurales y los intermediarios. Se recibieron 9 crónicas producto de los grupos de trabajo conformados por 4 o 5 estudiantes que evidencian un aprendizaje significativo a partir de historias de la vida real, presentan una secuencia coherente, guardan un hilo conductor y el 82 % de ellas incorporan en su contenido la mayoría de los determinantes sociales de la salud, destacando en su contenido los conceptos de equidad o inequidad, la igualdad o desigualdad, justicia o injusticia y la cohesión social. Conclusiones Un Ambiente Virtual de Aprendizaje, basado en un diseño instruccional adecuado, permite a través de un enfoque pedagógico constructivista facilitar el aprendizaje de los determinantes sociales de la salud a través del análisis de crónicas o historias de vida, construidas por estudiantes de noveno semestre de medicina de la Universidad de La Sabana.(AU)

Abstract Objective To describe the contributions of a pedagogical strategy based on the construction of chronicles, using a Virtual Learning Environment for training medical students from Universidad de La Sabana on social determinants of health Methodology Descriptive study with a qualitative approach. Design and implementation of a Virtual Learning Environment based on the ADDIE instructional model. Results A Virtual Learning Environment was implemented with an instructional design based on the five phases of the ADDIE model, on the grounds of meaningful learning and social constructivism, and through the narration of chronicles or life stories as a pedagogical strategy. During the course, the structural determinants and intermediaries were addressed, and nine chronicles were produced by working groups made up of four or five students, who demonstrated meaningful learning from real life stories, presented a coherent sequence, and kept a thread; 82% of these students incorporated in their contents most of the social determinants of health, emphasizing on the concepts of equity or inequity, equality or inequality, justice or injustice and social cohesion. Conclusions A Virtual Learning Environment, based on an appropriate instructional design, allows to facilitate learning of social determinants of health through a constructivist pedagogical approach by analyzing chronicles or life stories created by ninth-semester students of medicine from Universidad de La Sabana.(AU)

[Learning about social determinants of health through chronicles, using a virtual learning environment]. / Aprendiendo sobre determinantes sociales de la salud a través de crónicas, mediante un ambiente virtual de aprendizaje.

OBJECTIVE: To describe the contributions of a pedagogical strategy based on the construction of chronicles, using a Virtual Learning Environment for training medical students from Universidad de La Sabana on social determinants of health. METHODOLOGY: Descriptive study with a qualitative approach. Design and implementation of a Virtual Learning Environment based on the ADDIE instructional model. RESULTS: A Virtual Learning Environment was implemented with an instructional design based on the five phases of the ADDIE model, on the grounds of meaningful learning and social constructivism, and through the narration of chronicles or life stories as a pedagogical strategy. During the course, the structural determinants and intermediaries were addressed, and nine chronicles were produced by working groups made up of four or five students, who demonstrated meaningful learning from real life stories, presented a coherent sequence, and kept a thread; 82% of these students incorporated in their contents most of the social determinants of health, emphasizing on the concepts of equity or inequity, equality or inequality, justice or injustice and social cohesion. CONCLUSIONS: A Virtual Learning Environment, based on an appropriate instructional design, allows to facilitate learning of social determinants of health through a constructivist pedagogical approach by analyzing chronicles or life stories created by ninth-semester students of medicine from Universidad de La Sabana.

Guía de práctica clínica para la prevención, detección temprana y tratamiento de las complicaciones del embarazo, parto y puerperio: sección 3. Infecciones en el embarazo: ruptura prematura de membranas (RPM) / Clinical practice guideline for the prevention, early detection and treatment of pregnancy, delivery and post-partum complications: section 3. Infections in pregnancy: premature rupture of membranes (PROM)

Realizar recomendaciones para la atención del embarazo con ruptura prematura de membranas como parte integral de la Guía de Práctica Clínica (GPC) para la prevención, detección temprana y tratamiento de las complicaciones del embarazo en Colombia.Materiales y métodos: el grupo desarrollador de la Guía (GDG) elaboró esta GPC durante 2011-2012, acorde con la Guía Metodológica para la elaboración de Guías de Atención Integral en el Sistema General de Seguridad Social en Salud Colombiano, basándose en la evidencia científica disponible y sumando la participación activa de grupos de pacientes, sociedades científicas y grupos de interés. En particular, la evidencia de esta sección fue adaptada de la GPC "Preterm prelabour rupture of membranes" (Royal College of Obstetricians and Gynaecologists-2006) y actualizada por medio de procedimientos sistemáticos, tanto para la búsqueda y valoración de la evidencia como para la generación de recomendaciones. El nivel de evidencia y la fuerza de las recomendaciones fueron expresadas por medio del sistema del Scottish Intercollegiate Guidelines Network (SIGN).Resultados: se presentan las recomendaciones para la atención de los embarazos con ruptura prematura de membranas. Estas incluyen cambios en la conducta del personal de salud y las instituciones para aumentar la probabilidad de obtener un resultado materno fetal exitoso en las gestaciones con esta complicación.Conclusiones: se presenta una versión resumida de las recomendaciones y evidencia de esta sección, que se espera sea adoptada por los profesionales de salud encargados de la atención del embarazo en el país para disminuir la morbilidad y mortalidad asociada a la gestación...

Realizar recomendaciones para la atención del embarazo con ruptura prematura de membranas como parte integral de la Guía de Práctica Clínica (GPC) para la prevención, detección temprana y tratamiento de las complicaciones del embarazo en Colombia.Materiales y métodos: el grupo desarrollador de la Guía (GDG) elaboró esta GPC durante 2011-2012, acorde con la Guía Metodológica para la elaboración de Guías de Atención Integral en el Sistema General de Seguridad Social en Salud Colombiano, basándose en la evidencia científica disponible y sumando la participación activa de grupos de pacientes, sociedades científicas y grupos de interés. En particular, la evidencia de esta sección fue adaptada de la GPC "Preterm prelabour rupture of membranes" (Royal College of Obstetricians and Gynaecologists-2006) y actualizada por medio de procedimientos sistemáticos, tanto para la búsqueda y valoración de la evidencia como para la generación de recomendaciones. El nivel de evidencia y la fuerza de las recomendaciones fueron expresadas por medio del sistema del Scottish Intercollegiate Guidelines Network (SIGN).Resultados: se presentan las recomendaciones para la atención de los embarazos con ruptura prematura de membranas. Estas incluyen cambios en la conducta del personal de salud y las instituciones para aumentar la probabilidad de obtener un resultado materno fetal exitoso en las gestaciones con esta complicación.Conclusiones: se presenta una versión resumida de las recomendaciones y evidencia de esta sección, que se espera sea adoptada por los profesionales de salud encargados de la atención del embarazo en el país para disminuir la morbilidad y mortalidad asociada a la gestación...

Conización cervical más linfadenectomía pélvica radical bilateral comomanejo conservador del cáncer de cérvix IB 1: reporte de un caso y revisión de la literatura / Cervical conisation plus radical bilateral pelvic lymph node dissection as conservative treatment for cervical cancer IB1: case report and review of the literature

Objetivo: describir el caso de una paciente con cáncer de cérvix en estadio FIGO IB1, a quien se le realizó conización cervical más linfadenectomía pélvica para preservar su fertilidad, y hacer una revisión de la literatura sobre sus indicaciones, efectividad y seguridad en términos de resultados oncológicos y obstétricos.Materiales y métodos: se presenta el caso de una paciente de 26 años, con diagnóstico de adenocarcinoma infiltrante de cérvix estadio IB1, atendida en la Clínica Julio Enrique Medrano de SaludCoop, Barranquilla (Colombia), institución de alto nivel de complejidad que atiende pacientes pertenecientes al régimen contributivo del sistema de seguridad social. Se realizó conización cervical más linfadenectomía pélvica, para preservar fertilidad. Al segundo año de seguimiento logró embarazo a término y 48 meses después se encuentra libre de enfermedad. Se realizó una búsqueda electrónica, sin restricción de idioma, de la literatura publicada hasta julio de 2015 con las palabras claves: Uterine Cervical Neoplasms, Fertility Preservation, Conization, Gynecologic Surgical Procedures y Lymph Node Excision, en las bases de datos Medline, Embase, CINAHL y Cochrane, y en las referencias bibliográficas de estudios recuperados.Resultados: se identificaron nueve artículos: ocho estudios de cohorte y un de reporte de caso. La conización cervical más linfadenectomía pélvica radical bilateral, es un procedimiento menos radical, seguro y efectivo para el manejo conservador del cáncer de cérvix de bajo riesgo. En pacientes sometidas a conización se reportan recidivas en un 2,84 %; 38 % logran embarazo, de los cuales el 70,2 % llegan a término.Conclusiones: la conización cervical más linfadenectomía pélvica radical bilateral podría ser una opción para el manejo de pacientes con cáncer de cérvix en estadios iniciales considerados de bajo riesgo que deseen conservar su fertilidad

Objective: To describe the case of a patient with cervical cancer FIGO stage IB1 taken to conisation and pelvic lymphadenectomy with the aim of preserving fertility, and to conduct a search in the literature regarding indications, effectiveness and safety of this procedure in terms of obstetric and oncologic outcomes.Materials and methods: We present the case of a 26-year old female patient seen at the Julio Enrique Medrano SaludCoop Clinic (Barranquilla, Colombia), a high-complexity institution that serves a population belonging to the contributory regime of the social security system. The patient was diagnosed with infiltrating cervical carcinoma stage IB1. She was taken to cervical cone biopsy plus pelvic lymph node dissection in order to preserve fertility. Two years into follow-up she achieved a term pregnancy, and 48 months later she is disease-free. An online search was conducted of the literature published until July 2015, with no language restriction, using the key words Uterine Cer vical Neoplasms, Fertilit y Preser vation, Conization, Gynaecologic Surgical Procedures and Lymph Node Excision in the Medline, Embase, CINAHL and Cochrane databases and in the bibliographic references of retrieved studies.Results: Overall, 9 articles were identified: 8 cohort studies and 1 case report. Cervical conisation plus bilateral radical pelvic lymphadenectomy is a less radical, safer and effective procedure for the conservative management of low-risk cervical cancer. A relapse rate of 2.84 % has been reported in patients subjected to conisation, pregnancy is achieved in 38 % of cases and, of those, 70.2 % come to term.Conclusions: Cervical conisation plus bilateral radical pelvic lymphadenectomy may be a management option for patients with low-risk, early-stage cervical cancer who wish to preserve their fertility

Experiencia de las pacientes frente a citología cérvico-vaginal reportada como ASCUS o LEI de bajo grado en dos instituciones de Bogotá (Colombia), 2014 / Patient experiences regarding ASCUS or low grade SIL cervicovaginal cytology results in two institutions in Bogotá (Colombia), 2014

Describir los conocimientos que tienen las pacientes acerca del uso de la citología, y las emociones y el comportamiento que genera en estas un resultado positivo en la citología vaginal con atipias escamosas de significado indeterminado (ASCUS) o lesión escamosa intraepitelial de bajo grado (LEI-BG). Materiales y métodos: investigación cualitativa fenomenológica, que busca establecer las experiencias vividas por mujeres entre 18 y 69 años que consultaron por primera vez, por el hallazgo en la citología cérvico-vaginal de ASCUS o LEI-BG, a la unidad de patología cervical de dos instituciones de nivel medio de complejidad en Bogotá (Colombia), una institución pública y otra un centro de atención ambulatorio privado. El tamaño de la muestra se determinó por saturación teórica y muestreo consecutivo. Se realizaron grupos focales y entrevistas, la información fue grabada y transcrita posteriormente, creando categorías para evaluar las experiencias: caracterización sociodemográfica, cognición, características afectivas y comportamiento. Se empleó el estilo de análisis mediante edición, presentado como material narrativo, a fin de ordenar la información recolectada para su síntesis e interpretación. Resultados: se incluyeron 27 mujeres. El resultado anormal de la citología cérvico-vaginal despierta sentimientos de culpa, angustia y preocupación pues lo relacionan con el cáncer de cuello uterino, dado que no es claro para ellas que este es un examen de tamización. La principal conducta posterior a recibir el resultado de la citología fue priorizar la cita médica. Hay alteraciones en las relaciones de pareja basadas en la percepción de infidelidad secundaria a la infección de VPH. Conclusiones: la toma de la citología cérvico-vaginal es considerada por las pacientes como importantísima y obligatoria en el marco de la necesidad de prevenir y tratar el cáncer de cuello uterino...

To describe patient k nowledge regarding the use of cytology, as well as the emotions and behaviours elicited by a positive vaginal cytology result of atypical squamous cells of undetermined significance (ASCUS) or low-grade squamous intraepithelial lesion (LG-SIL). Materials and methods: Qualitative phenomenolog ical research aimed at identif y ing experiences among women between 18 and 69 years of age presenting for the first time because of a cervicovaginal cytology finding of ASCUS or LG-SIL to the cervical pathology units of two intermediate complexity centres in Bogota, one of them a public institution and the other a private outpatient centre. The sample size was determined by theoretical saturation on the basis of a consecutive sampling. Focus groups and inter views were conducted, and the information was recorded and transcribed afterwards. Categories were created for experience assessment: socio-demographic and affective characteristics, cognition, and behaviour. Editing was used for a narrative analysis style in order to organize the information gathered for synthesis and interpretation purposes. Results: Twenty-seven women were included. An abnormal cytology result gives rise to feelings of guilt and is associated with anxiety and fear of having cervical cancer, given that it is not clear to them that cervicovaginal cytology is a screening test. The main behaviour after receiving the cytology result was to give priority to the medical appointment. There are changes in the relationships with the partners due to perceived infidelity secondary to HPV infection. Conclusions: Cervicovaginal cytology is is considered by patients of the greatest importance and mandatory given the need to prevent and treat cervical cancer...