Tolerance for Uncertainty, Personality Traits and Specialty Choice Among Medical Students.

OBJECTIVE: The objective was to explore the tolerance for uncertainty in its different aspects (risk, ambiguity and complexity) in medical students at different times of their careers, and to relate these tolerance levels with their predominant personality traits and specialty choices. A secondary objective was to build a hypothetical model aimed at explaining the potential relationships of dependency between gender, personality traits, tolerance for uncertainty and specialty choice using a structural equation modeling (SEM) analysis. DESIGN/SETTING/PARTICIPANTS: A prospective cross-sectional study including two cohorts of second-year (n = 155) and sixth-year (n = 157) medical students was performed during 2017 at the Buenos Aires University School of Medicine. Both student cohorts completed instruments assessing tolerance for different types of uncertainty: (1) complexity (Tolerance for Ambiguity scale); (2) risk (Pearson Risk Attitude scale); and (3) ambiguity (Ambiguity Aversion in Medicine scale). Information on age, gender and specialty choice in sixth-year medical students was included, plus the Big Five Inventory-10 (BFI-10) personality test. RESULTS: Sixth-year students showed significantly lower scores than second-year students at tolerance for complexity (p = 0.0003) and ambiguity (p = 0.008). Sixth-year students choosing a surgical specialty were associated with low tolerance for risk and ambiguity, and moderate for complexity. Conversely, students choosing a clinical specialty were related with high tolerance for risk, moderate for ambiguity, and low for complexity. Logistic regression analysis including the uncertainty questionnaires plus BFI-10 categories demonstrated that only the "neuroticism" personality trait was independently associated with a surgical specialty choice (OR: 1.31, 95%CI: 1.03-1.67). The final SEM that best represented the data showed good fit statistics: chi-square (p = 0.108), and RMSEA (p = 0.047). CONCLUSIONS: Tolerance for uncertainty in its different dimensions was associated with personality traits and specialty choice among medical students. A SEM analysis could satisfactorily explain the hypothetical relationships of dependency between gender, personality traits, tolerance for uncertainty, and specialty choice.

Treatment of individual predictors with neural network algorithms improves Global Registry of Acute Coronary Events score discrimination.

Objective: The aim of this study was to develop, train, and test different neural network (NN) algorithm-based models to improve the Global Registry of Acute Coronary Events (GRACE) score performance to predict in-hospital mortality after an acute coronary syndrome. Methods: We analyzed a prospective database, including 40 admission variables of 1255 patients admitted with the acute coronary syndrome in a community hospital. Individual predictors included in GRACE score were used to train and test three NN algorithm-based models (guided models), namely: one- and two-hidden layer multilayer perceptron and a radial basis function network. Three extra NNs were built using the 40 admission variables of the entire database (unguided models). Expected mortality according to GRACE score was calculated using the logistic regression equation. Results: In terms of receiver operating characteristic area and negative predictive value (NPV), almost all NN algorithms outperformed logistic regression. Only radial basis function models obtained a better accuracy level based on NPV improvement, at the expense of positive predictive value (PPV) reduction. The independent normalized importance of variables for the best unguided NN was: creatinine 100%, Killip class 61%, ejection fraction 52%, age 44%, maximum creatine-kinase level 41%, glycemia 40%, left bundle branch block 35%, and weight 33%, among the top 8 predictors. Conclusions: Treatment of individual predictors of GRACE score with NN algorithms improved accuracy and discrimination power in all models with respect to the traditional logistic regression approach; nevertheless, PPV was only marginally enhanced. Unguided variable selection would be able to achieve better results in PPV terms.

Objetivo: El objetivo fue desarrollar, entrenar y probar diferentes modelos basados en algoritmos de redes neuronales (RN) para mejorar el rendimiento del score del Registro Global de Eventos Coronarios Agudos (GRACE) para predecir la mortalidad hospitalaria después de un síndrome coronario agudo. Métodos: Analizamos una base de datos prospectiva que incluía 40 variables de ingreso de 1255 pacientes con síndrome coronario agudo en un hospital comunitario. Las variables incluidas en la puntuación GRACE se usaron para entrenar y probar tres algoritmos basados en RN (modelos guiados), a saber: perceptrones multicapa de una y dos capas ocultas y una red de función de base radial. Se construyeron tres RN adicionales utilizando las 40 variables de admisión de toda la base de datos (modelos no guiados). La mortalidad esperada según el GRACE se calculó usando la ecuación de regresión logística. Resultados: En términos del área ROC y valor predictivo negativo (VPN), casi todos los algoritmos RN superaron la regresión logística. Solo los modelos de función de base radial obtuvieron un mejor nivel de precisión basado en la mejora del VPN, pero a expensas de la reducción del valor predictivo positivo (VPP). La importancia normalizada de las variables incluidas en la mejor RN no guiada fue: creatinina 100%, clase Killip 61%, fracción de eyección 52%, edad 44%, nivel máximo de creatina quinasa 41%, glucemia 40%, bloqueo de rama izquierda 35%, y peso 33%, entre los 8 predictores principales. Conclusiones: El tratamiento de las variables del score GRACE mediante algoritmos de RN mejoró la precisión y la discriminación en todos los modelos con respecto al enfoque tradicional de regresión logística; sin embargo, el VPP solo mejoró marginalmente. La selección no guiada de variables podría mejorar los resultados en términos de PPV.

Treatment of individual predictors with neural network algorithms improves Global Registry of Acute Coronary Events score discrimination / El tratamiento con redes neuronales de las variables del Global Registry of Acute Coronary mejora la discriminación del score

Abstract Objective: The aim of this study was to develop, train, and test different neural network (NN) algorithm-based models to improve the Global Registry of Acute Coronary Events (GRACE) score performance to predict in-hospital mortality after an acute coronary syndrome. Methods: We analyzed a prospective database, including 40 admission variables of 1255 patients admitted with the acute coronary syndrome in a community hospital. Individual predictors included in GRACE score were used to train and test three NN algorithm-based models (guided models), namely: one- and two-hidden layer multilayer perceptron and a radial basis function network. Three extra NNs were built using the 40 admission variables of the entire database (unguided models). Expected mortality according to GRACE score was calculated using the logistic regression equation. Results: In terms of receiver operating characteristic area and negative predictive value (NPV), almost all NN algorithms outperformed logistic regression. Only radial basis function models obtained a better accuracy level based on NPV improvement, at the expense of positive predictive value (PPV) reduction. The independent normalized importance of variables for the best unguided NN was: creatinine 100%, Killip class 61%, ejection fraction 52%, age 44%, maximum creatine-kinase level 41%, glycemia 40%, left bundle branch block 35%, and weight 33%, among the top 8 predictors. Conclusions: Treatment of individual predictors of GRACE score with NN algorithms improved accuracy and discrimination power in all models with respect to the traditional logistic regression approach; nevertheless, PPV was only marginally enhanced. Unguided variable selection would be able to achieve better results in PPV terms.

Resumen Objetivo: El objetivo fue desarrollar, entrenar y probar diferentes modelos basados en algoritmos de redes neuronales (RN) para mejorar el rendimiento del score del Registro Global de Eventos Coronarios Agudos (GRACE) para predecir la mortalidad hospitalaria después de un síndrome coronario agudo. Métodos: Analizamos una base de datos prospectiva que incluía 40 variables de ingreso de 1255 pacientes con síndrome coronario agudo en un hospital comunitario. Las variables incluidas en la puntuación GRACE se usaron para entrenar y probar tres algoritmos basados en RN (modelos guiados), a saber: perceptrones multicapa de una y dos capas ocultas y una red de función de base radial. Se construyeron tres RN adicionales utilizando las 40 variables de admisión de toda la base de datos (modelos no guiados). La mortalidad esperada según el GRACE se calculó usando la ecuación de regresión logística. Resultados: En términos del área ROC y valor predictivo negativo (VPN), casi todos los algoritmos RN superaron la regresión logística. Solo los modelos de función de base radial obtuvieron un mejor nivel de precisión basado en la mejora del VPN, pero a expensas de la reducción del valor predictivo positivo (VPP). La importancia normalizada de las variables incluidas en la mejor RN no guiada fue: creatinina 100%, clase Killip 61%, fracción de eyección 52%, edad 44%, nivel máximo de creatina quinasa 41%, glucemia 40%, bloqueo de rama izquierda 35%, y peso 33%, entre los 8 predictores principales. Conclusiones: El tratamiento de las variables del score GRACE mediante algoritmos de RN mejoró la precisión y la discriminación en todos los modelos con respecto al enfoque tradicional de regresión logística; sin embargo, el VPP solo mejoró marginalmente. La selección no guiada de variables podría mejorar los resultados en términos de PPV.

Remote ischaemic conditioning in patients with ST-elevation myocardial infarction treated with percutaneous coronary intervention: an updated meta-analysis of clinical outcomes.

BACKGROUND: All previous meta-analyses including clinical outcomes after remote ischaemic conditioning (RIC) in patients with ST-elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI) demonstrated that RIC significantly reduced all-cause mortality and major adverse cardiovascular events (MACE). Following the publication of these meta-analyses, three new randomised controlled clinical trials (RCT) including 5712 patients were reported. The objective of this study was to perform an updated meta-analysis about the effectiveness of RIC in reducing MACE in patients with STEMI undergoing PCI. METHODS: The search strategy included only RCT identified in MEDLINE, Embase, SCOPUS, and Cochrane (up to February 2020). Eligible studies included any type of RIC. The study adhered to the Preferred Reporting Items of Systematic Reviews and Meta-Analysis (PRISMA) statement. The studies quality was evaluated with Cochrane Risk of Bias tool and Jadad score. RESULTS: Twelve RCT were included in the analysis (Q = 18.8, p = 0.065, I2 = 41.5%, 95%CI 0.0-70.3). Globally, 8239 STEMI patients with 816 MACE were reported with follow-ups between 1 and 45 months. Random effects model showed no significant effect of RIC on composite clinical endpoints (OR = 0.77, 95%CI 0.59-1.01, p = 0.105). Sensitivity analysis demonstrated that only the exclusion of CONDI-2/ERIC PPCI trial modified the significance of the global effect (OR 0.66, 95%CI 0.47-0.93), favouring RIC intervention. CONCLUSIONS: The current updated meta-analysis showed that use of RIC around the time of PCI for STEMI treatment added no significant benefit for clinical outcomes assessed between 6 and 45 months after the procedure. These conclusions are in direct contrast to previously published meta-analyses.

Long-term outcomes of symptomatic and asymptomatic patients undergoing carotid endarterectomy in an average-volume community hospital.

BACKGROUND: Long-term benefit of carotid endarectomy has not yet been fully investigated in average volume centers. Thus our purpose is to evaluate long-term results of carotid endarterectomies at a medium-volume hospital. METHODS: A retrospective analysis of carotid artery stenosis operated between 2008 and 2017 in a community hospital was done. Demographic and postoperative outcomes were evaluated in short and long-term by Kaplan-Meier survival analysis. RESULTS: 167 procedures in 159 patients were included. Average age was 72 years, and 65% were men. Twenty-nine percent of the patients were symptomatic and the rest asymptomatic. Median hospitalization was 3 (IQR 3-4) days and the mean follow-up was 56 months. No hospital mortality was recorded. At 120-month follow-up, freedom of stroke was 97.4%, death 97.3%, restenosis, 98.7% and all combined events 92.9% (log rank p = .042) Combined event-free survival was 84.4% in symptomatic patients, and 96.1% in asymptomatic patients (log rank p = .025). CONCLUSIONS: In a medium-volume hospital combined event-free survival was 84.4% in symptomatic patients and 96.1% in asymptomatic at a 10-year follow-up.

Three-dimensional virtual and printed models for planning adult cardiovascular surgery.

BACKGROUND: The objective of this study was to explore the usefulness of virtual models and three-dimensional (3D) printing technologies for planning complex non-congenital cardiovascular surgery. METHODS: Between July 2018 and December 2019, adult patients with different cardiovascular structural diseases were included in a clinical protocol to explore the usefulness of Standard Tessellation Language (STL)-based virtual models and 3D printing for prospectively planning surgery. A qualitative descriptive analysis from the surgeon's viewpoint was done based on the characteristics, advantages and usefulness of 3D models for guiding, planning and simulating the surgical procedures. RESULTS: A total of 14 custom 3D-printed heart and great vessel replicas with their corresponding 3D virtual models were created for preoperative surgical planning. Six of 14 models helped to redefine the surgical approach, 3 were useful to verify device delivery, while the rest did not change the surgical decision. In all open surgery cases, cardiac and vascular anatomy accuracy of virtual and physical 3D replicas was validated by direct visualisation of the organs during surgery. Printing was achieved through an external provider associated with the Hospital, who printed the final prototype in 5-7 days. Printed production cost was between 100 and 500 USD per model. CONCLUSIONS: In the current study, the selected 3D printed models presented different advantages (visual, tactile, and instrumental) over the traditional flat anatomical images when simulating and planning some complex types of surgery. Notwithstanding 3D printing advantages, STL-based virtual models were pre-printing useful tools when instrumentation on a physical replica was not required.

Resultados a corto plazo de la cirugía coronaria aislada o combinada en mujeres / Short-Term Outcomes of Isolated and Combined Coronary Artery Bypass Graft Surgery in Women

RESUMEN Introducción: En relación con la cirugía coronaria, existen discrepancias respecto del pronóstico y tratamiento de la enfermedad cardiovascular en la mujer entre distintos estudios internacionales. Objetivo: Analizar los resultados de mortalidad y complicaciones hospitalarias y a 60 días luego de la cirugía de revascularización miocárdica aislada o combinada, en forma comparativa entre mujeres y varones. Material y métodos: Se analizaron en forma retrospectiva los resultados hospitalarios y a 60 días de la cirugía de revascularización coronaria aislada o combinada de acuerdo con el sexo, operados entre 2011 y 2017. Se compararon las variables perioperatorias, la mortalidad esperada con el EuroSCORE II y la mortalidad observada por toda causa. Se realizó un análisis de propensión para equiparar las poblaciones de mujeres y varones. Resultados: De 1670 cirugías de revascularización coronaria aisladas o combinadas, el 27,4% (n: 457) eran mujeres; y, de 1305 cirugías aisladas, el 14,2% (n: 185) eran mujeres. La mortalidad en las mujeres a 30 y 60 días fue del 2,7% y del 4,3% vs. el 2,1% (RR = 1,26 IC95% 0,49-3,26, p = 0,632) y el 2,3% (RR = 1,86 IC95% 0,86-4,05, p = 0,113, potencia 53%) en los varones. Tras el análisis de propensión de los pacientes sometidos a cirugía coronaria asilada, la mortalidad a 60 días en las mujeres fue del 4,0% vs. 2,3% en los varones (RR = 1,75 IC95% 0,52-5,87, p = 0,359). Conclusiones: En comparación con los varones, las mujeres sometidas a cirugía de revascularización coronaria tuvieron más edad y mayor riesgo esperado por el EuroSCORE II, peor función renal tanto para la cirugía coronaria combinada como aislada. La mortalidad luego de la cirugía de revascularización coronaria aislada o combinada fue mayor en mujeres que en hombres a 60 días e, incluso, esta diferencia se mantuvo después de ajustar por confundidores.

ABSTRACT Background: The outcome and treatment of cardiovascular disease in women differ among international studies. Objective: The aim of this study was to compare in-hospital mortality and complications with mortality and complications at 60 days following isolated or combined coronary artery bypass graft surgery between women and men. Methods: The outcomes during hospitalization and at 60 days following isolated or combined coronary artery bypass graft surgery procedures performed between 2011 and 2017 were retrospectively analyzed. Perioperative variables, expected all-cause mortality estimated by EuroSCORE II and observed all-cause mortality were compared. A propensity score analysis was performed to match female and male populations. Results: Of the 1670 isolated or combined coronary artery bypass graft procedures, 27.4% (n=457) were performed in women, and 185 (14.2%) of 1305 isolated surgeries corresponded to women. Mortality in women at 30 and 60 days was 2.7% and 4.3%. respectively, vs. 2.1% (RR: 1.26; 95% CI, 0.49-3.26; p=0.632) and 2.3% (RR: 1.86; 95% CI, 0.86-4.05, p=0.113, power 53%), respectively, in men. After analyzing the propensity score of patients undergoing isolated revascularization procedures, 60-day mortality in women was 4.0% vs. 2.3% in men (RR: 1.75; 95% CI; 0.52-5.87, p=0.359). Conclusions: Compared with men, women undergoing isolated or combined coronary artery bypass graft surgery were older and had higher expected risk calculated by EuroSCORE II and worse renal function. Mortality after isolated or combined coronary artery bypass graft surgery was higher in women than in men at 60 days, and this difference remained even after adjusting for confounders.

Forecasting the effect of social distancing on COVID-19 autumn-winter outbreak in the metropolitan area of Buenos Aires.

Forecasting the extent of the domestic health risk of epidemics by mathematical modeling is a useful tool for evaluating the feasibility of policies for controlling outbreaks. The objective of this study was to develop a time-dependent dynamic simulation model to forecast the COVID-19 autumn-winter outbreak in the metropolitan area of Buenos Aires, and to assess the effect of social distancing on epidemic spread. The model used was the "Susceptible-Exposed-Infectious-Recovered" framework which incorporated appropriate compartments relevant to interventions such as quarantine, isolation and treatment. In a low-intervention scenario including only 2-week isolation for international travelers and their contacts, the model estimated a maximum peak of nearly 90 000 symptomatic cases for early May. For an intervention scenario with mandatory quarantine during a 5-month period, the curve of cases flattened and receded as the proportion of quarantined individuals increased. The maximum peak was expected to appear between May 8 and Jul 8 depending on the quarantine strategy, and the average number of infectious symptomatic cases were 46 840, 30 494, 23 164, 16 179, and 13 196 when 10%, 20%, 30%, 40%, and 50% of the population remained in a 5-month-term continuous quarantine, respectively. Only mandatory quarantine was able to delay the maximum peak of infection and significantly reduce the total number of infected individuals and deaths at a 150-day term. The interruption of the quarantine before 120 days of its beginning could generate an even more serious outbreak 30 days later, and surpass the scarce medical resources available for the intensive care of critically-ill patients.

La estimación mediante modelos matemáticos del efecto de una epidemia sobre la salud pública constituye una herramienta útil para evaluar la viabilidad de las políticas tendientes a controlar el brote. El objetivo de este estudio fue desarrollar un modelo de simulación dinámica dependiente del tiempo para pronosticar el brote de otoño-invierno de COVID-19 en el área metropolitana de Buenos Aires y evaluar el efecto del distanciamiento social en la propagación de la epidemia. El modelo utilizado fue el de "Susceptible-Expuesto-Infeccioso-Recuperado" que incorporó compartimentos para evaluar posibles intervenciones tales como cuarentena, aislamiento y tratamiento. En un escenario de baja intervención que incluye solo 2 semanas de aislamiento para viajeros internacionales y sus contactos, el modelo estimó un pico máximo de casi 90 000 casos sintomáticos para principios de mayo. Para un escenario de intervención con cuarentena obligatoria durante un período de 5 meses, la curva de casos se aplanó y se alejó a medida que aumentaba la proporción de individuos en cuarentena. Se constató que el pico máximo aparecía entre el 8 de mayo y el 8 de julio, según la estrategia de cuarentena, y el número promedio de casos sintomáticos infecciosos fue 46 840, 30 494, 23 164, 16 179 y 13 196 cuando el 10%, 20%, 30%, 40% y 50% de la población permaneció en una cuarentena continua de 5 meses, respectivamente. Solo la cuarentena obligatoria fue capaz de retrasar el pico máximo de infección y reducir significativamente el número total de individuos infectados y muertes en un plazo de 150 días. La interrupción de la cuarentena antes de los 120 días de su inicio podría generar un brote aún más grave 30 días después y sobrepasar los escasos recursos médicos disponibles para el cuidado intensivo de pacientes críticos.

What patients consider to be a good doctor, and what doctors consider to be a good patient / Cómo definen los pacientes a un buen médico, y cómo definen los médicos a un buen paciente

ABSTRACT Background: From a patient's point of view, an 'ideal' doctor could be defined as one having personal qualities for interpersonal relationships, technical skills and good intentions. However, doctors' opinions about what it means to be a 'good' patient have not been systematically investigated. Aim: To explore how patients define the characteristics of a 'good' and a 'bad' doctor, and how doctors define a 'good' and a 'bad' patient. Material and Methods: We surveyed a cohort of 107 consecutive patients attending a community teaching hospital in February 2019, who were asked to define the desirable characteristics of a good/bad doctor. Additionally, a cohort of 115 physicians working at the same hospital was asked to define the desirable characteristics of a good/bad patient. Responses were subjected to content analysis. Simultaneously, an algorithm in Python was used to automatically categorize responses throughout text-mining. Results: The predominant patients' perspective alluded to desirable personal qualities more importantly than proficiency in knowledge and technical skills. Doctors would be satisfied if patients manifested positive personality characteristics, were prone to avoid decisional and personal conflicts, had a high adherence to treatment, and trusted the doctor. The text-mining algorithm was accurate to classify individuals' opinions. Conclusions: Ideally, fusing the skills of the scientist to the reflective capabilities of the medical humanist will fulfill the archetype of what patients consider to be a 'good' doctor. Doctors' preferences reveal a "paternalistic" style, and his/her opinions should be managed carefully to avoid stigmatizing certain patients' behaviors.

Antecedentes: Desde la perspectiva del paciente, un médico "ideal" podría definirse como aquel que tiene cualidades para las relaciones interpersonales, habilidades técnicas y buenas intenciones. Sin embargo, las opiniones de los médicos sobre lo que significa ser un "buen" paciente no se han investigado sistemáticamente. Objetivo: Explorar cómo los pacientes definen las características de un "buen" y "mal" médico, y cómo los médicos definen un "buen" y "mal" paciente. Material y Métodos: Encuestamos a una cohorte de 107 pacientes consecutivos que asistieron a un hospital comunitario en febrero de 2019, a quienes se les pidió que definieran las características deseables de un médico bueno/malo. Además, se pidió a una cohorte de 115 médicos que trabajaban en el mismo hospital que definieran las características deseables de un paciente bueno/malo. Las respuestas se sometieron a un análisis de contenido. Simultáneamente, se utilizó un algoritmo en Python para clasificar automáticamente las respuestas mediante minería de texto. Resultados: Los pacientes aludieron que las cualidades personales del médico eran más importantes que la competencia en conocimiento y las habilidades técnicas. Los médicos estarían satisfechos si los pacientes mostraran características positivas de personalidad, fueran propensos a evitar conflictos, tuvieran una alta adherencia al tratamiento y confiaran en el médico. El algoritmo de minería de texto clasificó las opiniones de los encuestados en forma precisa. Conclusiones: Idealmente, fusionar las habilidades del científico con las capacidades reflexivas del médico humanista cumplirá con el arquetipo de lo que los pacientes consideran un "buen" médico. Las preferencias de los médicos revelan un estilo "paternalista", y sus opiniones deben manejarse con cuidado para evitar estigmatizar los comportamientos de ciertos pacientes.

Forecasting the effect of social distancing on COVID-19 autumn-winter outbreak in the metropolitan area of Buenos Aires

Forecasting the extent of the domestic health risk of epidemics by mathematical modeling is a useful tool for evaluating the feasibility of policies for controlling outbreaks. The objective of this study was to develop a time-dependent dynamic simulation model to forecast the COVID-19 autumn-winter outbreak in the metropolitan area of Buenos Aires, and to assess the effect of social distancing on epidemic spread. The model used was the 'Susceptible-Exposed-Infectious-Recovered' framework which incorporated appropriate compartments relevant to interventions such as quarantine, isolation and treatment. In a low-intervention scenario including only 2-week isolation for international travelers and their contacts, the model estimated a maximum peak of nearly 90 000 symptomatic cases for early May. For an intervention scenario with mandatory quarantine during a 5-month period, the curve of cases flattened and receded as the proportion of quarantined individuals increased. The maximum peak was expected to appear between May 8 and Jul 8 depending on the quarantine strategy, and the average number of infectious symptomatic cases were 46 840, 30 494, 23 164, 16 179, and 13 196 when 10%, 20%, 30%, 40%, and 50% of the population remained in a 5-month-term continuous quarantine, respectively. Only mandatory quarantine was able to delay the maximum peak of infection and significantly reduce the total number of infected individuals and deaths at a 150-day term. The interruption of the quarantine before 120 days of its beginning could generate an even more serious outbreak 30 days later, and surpass the scarce medical resources available for the intensive care of critically-ill patients.

La estimación mediante modelos matemáticos del efecto de una epidemia sobre la salud pública constituye una herramienta útil para evaluar la viabilidad de las políticas tendientes a controlar el brote. El objetivo de este estudio fue desarrollar un modelo de simulación dinámica dependiente del tiempo para pronosticar el brote de otoño-invierno de COVID-19 en el área metropolitana de Buenos Aires y evaluar el efecto del distanciamiento social en la propagación de la epidemia. El modelo utilizado fue el de "Susceptible-Expuesto-Infeccioso-Recuperado" que incorporó compartimentos para evaluar posibles intervenciones tales como cuarentena, aislamiento y tratamiento. En un escenario de baja intervención que incluye solo 2 semanas de aislamiento para viajeros internacionales y sus contactos, el modelo estimó un pico máximo de casi 90 000 casos sintomáticos para principios de mayo. Para un escenario de intervención con cuarentena obligatoria durante un período de 5 meses, la curva de casos se aplanó y se alejó a medida que aumentaba la proporción de individuos en cuarentena. Se constató que el pico máximo aparecía entre el 8 de mayo y el 8 de julio, según la estrategia de cuarentena, y el número promedio de casos sintomáticos infecciosos fue 46 840, 30 494, 23 164, 16 179 y 13 196 cuando el 10%, 20%, 30%, 40% y 50% de la población permaneció en una cuarentena continua de 5 meses, respectivamente. Solo la cuarentena obligatoria fue capaz de retrasar el pico máximo de infección y reducir significativamente el número total de individuos infectados y muertes en un plazo de 150 días. La interrupción de la cuarentena antes de los 120 días de su inicio podría generar un brote aún más grave 30 días después y sobrepasar los escasos recursos médicos disponibles para el cuidado intensivo de pacientes críticos.

Continuous Monitoring of Coronary Care Mortality Using the Global Registry for Acute Coronary Events (GRACE) Score.

BACKGROUND: The aim was to assess the utility of cumulative sum techniques for continuous monitoring of coronary care outcomes, applied to patients with acute coronary syndrome stratified by the Global Registry for Acute Coronary Events (GRACE) risk score. METHODS: A prospective longitudinal study to assess GRACE score for real-time monitoring of coronary care mortality in a community hospital was conducted between January 2012 and December 2017. An expected-to-observed probability of death chart for individual risk and a variable life-adjusted display were used to monitor the results. RESULTS: A total of 1,255 patients undergoing acute coronary syndrome were included in the analysis. GRACE-based variable life-adjusted plots monitoring in-hospital mortality showed that observed death rates remained in general within the expected 95% confidence limit over time, and these behaviors were similar for ST-segment elevation and non-ST-segment elevation myocardial infarction. In-hospital all-cause mortality was 2.6% for the overall population, and 56% of these cases corresponded to unexpected deaths; conversely, unexpected survival occurred in 5.2% of survivors. CONCLUSIONS: Continuous monitoring of coronary care mortality based on cumulative sum charts and the GRACE score demonstrated the occurrence of series of favorable and unfavorable outcomes on a real-time basis. Additionally, plotting the expected-to-observed probability of death for individual cases was useful to individualize unexpected deaths in low-risk patients. Although overall coronary care performance was adequate according to the GRACE score, we found that there is still some room for improvement, since over half of the deaths occurring in low-risk patients were potentially preventable.

Metaanálisis sobre los resultados a 30 días del implante valvular aórtico transcatéter en pacientes con riesgo intermedio en Argentina / Single-arm Meta-analysis of Argentine Studies Reporting 30-Day Mortality After Transcatheter Aortic Valve Implantation in Intermediate Risk Patients

RESUMEN Introducción: El implante valvular aórtico transcatéter (TAVI) ha mostrado ser beneficioso en los pacientes con riesgo intermedio; sin embargo,no existe ningún análisis del conjunto de los resultados del TAVI en nuestro país. Objetivos: Realizar un metaanálisis de estudios locales de grupo único sobre los resultados hospitalarios del TAVI en pacientes de riesgo intermedio en Argentina. Métodos: Se realizó una revisión sistemática utilizando estudios observacionales de TAVI identificados en MEDLINE, Embase, SCOPUS y Cochrane hasta agosto de 2019. Resultados: De los 59 estudios identificados a través de la citada búsqueda, solamente 4 estudios observacionales locales comunicaban la mortalidad a 30 días y las complicaciones posteriores al TAVI en pacientes de riesgo moderado, según el puntaje de la STS (Society of Thoracic Surgeons) -entre 4 y 7%-. En 494 pacientes, la mortalidad a 30 días fue del 4,8%. Las estimaciones ponderadas del conjunto de estudios arrojaron estos valores: accidente vascular cerebral, 2,7%; infarto de miocardio,1,0%; necesidad de marcapasos definitivo, 24,8%; fuga paravalvular moderada o grave, 16,7%; y sangrado mayor, 5,5%. Conclusiones: La eficacia demostrada del TAVI está generando una expansión de su indicación a pacientes con riesgo intermedio y bajo; sin embargo, este avance debería estar apoyado por evidencia local de su beneficio por sobre la cirugía valvular tradicional. Este metaanálisis de estudios de grupo único realizados en el país presenta la mortalidad a 30 días y las complicaciones posteriores al TAVI en pacientes de riesgo intermedio. La información actualizada de los resultados locales del TAVI servirá como un estándar en nuestro medio.

ABSTRACT Background: Transcatheter aortic valve implantation (TAVI) has been shown to be beneficial in patients with intermediate risk; however, there is no overall analysis reporting TAVI results in our country. Objectives: To conduct a single-arm meta-analysis of local studies reporting 30-day outcomes after TAVI in intermediate risk patients in Argentina. Methods: A systematic review on TAVI was performed using controlled trials and observational studies identified in MEDLINE, Embase, SCOPUS and Cochrane to August 2019. Results: Among 59 articles identified through the database search, only 4 local observational studies reported 30-day mortality and complications after TAVI in moderate-risk patients according to the STS (Society of Thoracic Surgeons) score ranging between 4 and 7%. In 494 patients, 30-day mortality was 4.8%. Weighted pooled estimates of the studies were: stroke 2.7%, myocardial infarction 1.0%, need for a definitive pacemaker 24.8%, moderate or severe periprosthetic leakage 16.7%, and major bleeding 5.5%. Conclusions: The proven efficacy of TAVI is generating an expansion of its indication to patients with intermediate and low risk, However, this shift should be supported by local evidence of its benefit over traditional valve surgery. This single-arm meta-analysis of Argentine studies presents 30-day mortality and complications after TAVI in intermediate risk patients. The updated information of the local TAVI outcomes will serve as a standard in our settings.

Supervivencia de la cirugía coronaria de múltiples vasos en el seguimiento hasta 20 años / Long-term survival of multi-vessel coronary surgery bypass grafting up to 20 years of follow-up

RESUMEN Introducción: Los resultados del seguimiento a largo plazo constituyen uno de los mejores parámetros para evaluar la calidad de una intervención médica. Objetivos: Analizar la supervivencia global y la supervivencia libre de eventos cardiovasculares a 20 años de la cirugía coronaria en un hospital de comunidad con historia clínica electrónica de larga data. Métodos: Se estudiaron en forma retrospectiva los resultados alejados de las cirugías coronarias aisladas efectuadas en pacientes con enfermedad de múltiples vasos o tronco de coronaria izquierda entre 1999 y 2003 en un hospital de comunidad. El seguimiento hasta 20 años se realizó a través de la historia clínica electrónica. Resultados: Se logró un tiempo de seguimiento medio de 125 meses (rango: 6-268) en 254 pacientes de los 272 operados en ese período (93,4%). El número promedio de puentes fue 3,3 (desvío estándar: 0,97); en 97,6% se usó al menos una arteria mamaria y 59,4% recibieron un puente con arteria radial. Se obtuvo un seguimiento de 2646 pacientes-años, con un riesgo anual de muerte por toda causa de 2,5%. La supervivencia global al seguimiento medio fue de 0,806 (error estándar, EE: 0,03), y la supervivencia libre de eventos cardiovasculares fue de 0,826 (EE: 0,03). Conclusiones: El registro electrónico completo de los afiliados a un hospital de comunidad operados hace más de 15 años permitió analizar la supervivencia global y libre de eventos a largo plazo. Estos resultados servirán como estándar al momento de elegir entre la cirugía y la angioplastia de múltiples vasos.

ABSTRACT Background: The outcomes of long-term follow-up constitute one of the best parameters to assess the quality of a medical intervention. Objectives: To analyze the overall and the free-of-cardiovascular events 20-year survival after coronary surgery in a community hospital with a long-standing electronic medical records. Methods: The results of coronary surgeries in patients with multi-vessel or trunk disease operated between 1999 and 2003 in a community hospital were retrospectively studied. The follow-up up to 20 years was carried out through the electronic medical record. Results: Of 272 patients operated, a mean follow-up of 125 months (range 6-268) was achieved in 254 (93.4%). The average number of bypasses was 3.3 (standard deviation 0.97); in 97.6%, at least one internal mammary artery was used and 59.4% received a radial artery graft. A follow-up of 2646 patient-years was obtained with an annual risk of death from all causes of 2.5%. The overall survival at the mean follow-up time was 0.806 (standard error (SE) 0.03), and the cardiovascular event-free survival 0.826 (SE 0.03). Conclusions: The complete electronic registration of affiliates to a community hospital operated more than 15 years ago allowed us to analyze the overall survival and the freedom of long-term events. These results will serve as a standard when choosing between surgery and multi-vessel angioplasty.

What patients consider to be a 'good' doctor, and what doctors consider to be a 'good' patient.

BACKGROUND: From a patient's point of view, an 'ideal' doctor could be defined as one having personal qualities for interpersonal relationships, technical skills and good intentions. However, doctors' opinions about what it means to be a 'good' patient have not been systematically investigated. AIM: To explore how patients define the characteristics of a 'good' and a 'bad' doctor, and how doctors define a 'good' and a 'bad' patient. MATERIAL AND METHODS: We surveyed a cohort of 107 consecutive patients attending a community teaching hospital in February 2019, who were asked to define the desirable characteristics of a good/bad doctor. Additionally, a cohort of 115 physicians working at the same hospital was asked to define the desirable characteristics of a good/bad patient. Responses were subjected to content analysis. Simultaneously, an algorithm in Python was used to automatically categorize responses throughout text-mining. RESULTS: The predominant patients' perspective alluded to desirable personal qualities more importantly than proficiency in knowledge and technical skills. Doctors would be satisfied if patients manifested positive personality characteristics, were prone to avoid decisional and personal conflicts, had a high adherence to treatment, and trusted the doctor. The text-mining algorithm was accurate to classify individuals' opinions. CONCLUSIONS: Ideally, fusing the skills of the scientist to the reflective capabilities of the medical humanist will fulfill the archetype of what patients consider to be a 'good' doctor. Doctors' preferences reveal a "paternalistic" style, and his/her opinions should be managed carefully to avoid stigmatizing certain patients' behaviors.

Multicenter prospective validation of the EuroSCORE II in Argentina.

Objective: To validate prospectively in multiple centers, the accuracy and clinical utility of the European System for Cardiac Operative Risk Evaluation (EuroSCORE II) to predict the operative mortality of cardiac surgery in Argentina. Methods: Between January 2012 and February 2018, 2,000 consecutive adult patients who underwent cardiac surgery in different centers in Argentina were prospectively included. The end-point was in-hospital all-cause mortality. Discrimination, calibration, precision and clinical utility of the EuroSCORE II were evaluated in the global cohort and in the different types of surgeries, based on ROC (Receiver Operating Characteristics) curves, Hosmer-Lemeshow goodness-of-fit test, observed/expected mortality ratio, Shannon index and decision curves analysis. Results: ROC area of the EuroSCORE II was between 0.73 and 0.80 for all types of surgery, being the lowest value for coronary surgery. The observed and expected mortality was 4.3% and 3.0%, respectively (p = 0.034). The decision curve analysis showed a positive net benefit for all thresholds below 0.24, considering all type of surgeries. Conclusion: The EuroSCORE II showed an adequate performance in terms of discrimination and calibration for all types of surgery, although somewhat inferior for coronary surgery. Though in general terms this model underestimated the risk in intermediate risk groups, its overall performance was acceptable. The EuroSCORE II could be considered an optional updated generic model of operative risk stratification to predict in-hospital mortality after cardiac surgery in our context.

Objetivo: Validar, en forma prospectiva y en múltiples centros, la precisión y utilidad clínica del European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) para predecir la mortalidad operatoria de la cirugía cardíaca en centros de Argentina. Método: Entre enero de 2012 y febrero de 2018 se incluyeron en forma prospectiva 2,000 pacientes consecutivos que fueron sometidos a cirugía cardíaca en diferentes centros de Argentina. El punto final fue mortalidad hospitalaria por cualquier causa. La discriminación, calibración, precisión y utilidad clínica del EuroSCORE II se evaluaron en la cohorte global y en los diferentes tipos de cirugías, basándose en las curvas Receiver Operating Characteristics (ROC), bondad de ajuste de Hosmer-Lemeshow, razón de mortalidad observada/esperada, índice de Shannon y curvas de decisión. Resultados: El área ROC del EuroSCORE II estuvo entre 0.73 y 0.80 para todo tipo de cirugía, y el valor más bajo fue para la cirugía coronaria. La mortalidad observada y esperada fue 4.3 y 3.0%, respectivamente (p = 0.034). El análisis de la curva de decisión demostró un beneficio neto positivo para los umbrales por debajo de 0.24 para todo tipo de cirugía. Conclusiones: El EuroSCORE II tuvo un desempeño adecuado en términos de discriminación y calibración para todos los tipos de cirugía, aunque algo inferior para la cirugía coronaria. Si bien en términos generales subestimó el riesgo en los grupos de riesgo intermedio, el comportamiento global fue aceptable. El EuroSCORE II podría considerarse una opción de modelo genérico y actualizado de estratificación del riesgo operatorio para predecir la mortalidad hospitalaria de la cirugía cardíaca en nuestro contexto.

Técnica del debranching híbrido tipo I del arco aórtico sin circulación extracorpórea / Type I hybrid aortic arch debranching without cardiopulmonary bypass

Los aneurismas del cayado aórtico representan un desafío, ya que el involucramiento de sus grandes ramas exige una técnica quirúrgica compleja. A partir de la aparición del tratamiento endovascular, una alternativa desarrollada en los últimos años para abordar el cayado aórtico consistió en el tratamiento híbrido de esta patología, mediante la derivación quirúrgica de los vasos del cuello y la posterior exclusión del aneurisma con una endoprótesis. Este método híbrido es conocido con el nombre de debranching, y en forma simplificada consiste en realizar, sin circulación extracorpórea, una serie de puentes entre la aorta ascendente y el tronco braquiocefálico, la arteria carótida izquierda y eventualmente la arteria subclavia izquierda, para permitir avanzar una endoprótesis que cubra toda la luz del aneurisma. Se describe la técnica quirúrgica del debranching híbrido tipo I, sin el auxilio de la circulación extracorpórea e implante anterógrado de la endoprótesis, para los aneurismas del cayado aórtico.

Aortic arch aneurysms represent a major challenge as the involvement of the supra-aortic vessels demands a complex surgical technique. Since the advent of endovascular aortic repair, hybrid treatment of aortic arch disease has emerged in recent years. The procedure consists of surgical bypass of the supra-aortic vessels followed by exclusion of the aneurysm with an endograft. This hybrid method is known as debranching and, briefly, consists in performing bypasses between the ascending aorta and the brachiocephalic artery, the left carotid artery and possibly the left subclavian artery without cardiopulmonary bypass, in order to advance an endograft to cover the entire lumen of the aneurysm. The aim of this paper is to describe the surgical technique of type I hybrid debranching without cardiopulmonary bypass and antegrade endograft delivery to treat aortic arch aneurysms.