Salud digital en América Latina: legislación actual y aspectos éticos / Digital health in Latin America: current legislation and ethical aspects / Saúde digital na América Latina: legislação atual e aspectos éticos

[RESUMEN]. Objetivo. Describir la legislación vigente respecto a historia clínica electrónica (HCE) y telesalud de los países latinoamericanos y analizar el tratamiento de la confidencialidad y el secreto profesional. Métodos. Entre marzo y septiembre de 2022, se realizó un relevamiento de la reglamentación vigente en los 21 países latinoamericanos en estudio, en dos niveles: i) la existencia de legislación respecto a la HCE y la telesalud, y ii) el tratamiento de la confidencialidad y el secreto profesional en la HCE y la telesalud. Se con- feccionó una ficha de extracción de datos por país. Se recolectaron datos a partir de fuentes on-line oficiales. Se analizó cualitativamente la información y se sintetizó en forma de tablas cuando fue posible. Resultados. El uso de la HCE está reglamentado legalmente en 16 países. Para el caso de telesalud, son 19 países los que cuentan con legislación en referencia a esta herramienta. Todos los países analizados resguardan la confidencialidad y el secreto profesional a través de reglamentaciones. Sin embargo, en el contexto de telesalud se mencionan en 11 países, en tanto en el contexto de la HCE, solo en 9 países. Conclusiones. Desde el inicio del segundo milenio América Latina ha avanzado respecto a la legislación de herramientas digitales en la atención en salud como la HCE y la telesalud. Se observa a su vez un interés por las cuestiones éticas relacionadas con el uso de la HCE y la telesalud, en particular de la confidencialidad y secreto profesional, aunque dichos aspectos deben ser fortalecidos en la salud digital.

[ABSTRACT]. Objectives. Describe the current legislation on electronic medical records (EMR) and telehealth in Latin Ame- rican countries and analyze the treatment of confidentiality and professional secrecy. Methods. Between March and September 2022, a survey of the regulations in force in 21 Latin American countries was conducted at two levels: the existence of legislation on EMR and telehealth, and the treatment of confidentiality and professional secrecy in EMR and telehealth. A data extraction form was prepared for each country. Data were collected from official on-line sources. The information was analyzed qualitatively and synthesized in tables when possible. Results. The use of EMR is legally regulated in 16 countries. Nineteen countries have legislation on telehealth. All the countries analyzed safeguard confidentiality and professional secrecy through regulations. However, confidentiality and professional secrecy are mentioned in 11 countries in the context of telehealth, and in only nine countries in the context of EMR. Conclusions. Since the start of this century, Latin America has made progress in the legislation of digital tools for health care, such as EMR and telehealth. There is also interest in ethical issues related to the use of EMR and telehealth, particularly confidentiality and professional secrecy, aspects that should be strengthened in digital health.

[RESUMO]. Objetivo. Descrever a legislação vigente sobre prontuários eletrônicos e telessaúde nos países da América Latina e analisar o tratamento da confidencialidade e do sigilo profissional. Métodos. Entre março e setembro de 2022, realizou-se um levantamento sobre a regulamentação vigente nos 21 países latino-americanos incluídos no estudo, em dois níveis: i) existência de legislação sobre prontuários eletrônicos e telessaúde; e ii) tratamento da confidencialidade e do sigilo profissional em prontuários eletrônicos e telessaúde. Uma planilha para extração de dados foi elaborada para cada país. Os dados foram coletados de fontes oficiais disponíveis on-line. Foi realizada uma análise qualitativa das informações, que foram resumidas em tabelas, quando possível. Resultados. O uso dos prontuários eletrônicos é legalmente regulamentado em 16 países. Quanto à telessaúde, 19 países têm legislação sobre essa ferramenta. Todos os países analisados protegem a confidencialidade e o sigilo profissional por meio de regulamentação. No entanto, no contexto da telessaúde, eles são mencionados em 11 países; já no contexto dos prontuários eletrônicos, em apenas 9 países. Conclusões. Desde o início dos anos 2000, a América Latina vem avançando em relação à legislação sobre ferramentas digitais na atenção à saúde, como prontuários eletrônicos e telessaúde. Há também interesse nas questões éticas relacionadas ao uso de prontuários eletrônicos e telessaúde, especialmente em relação à confidencialidade e ao sigilo profissional, embora esses aspectos precisem ser reforçados na saúde digital.

Esteroides y COVID-19: una revisión de la evidencia en crecimiento durante la pandemia / Steroids and COVID-19: a review of growing evidence during the pandemic

El mecanismo específico por el cual los esteroides actuarían sobre la inflamación pulmonar sostenida, así como la definición del mejor fármaco a utilizar e incluso la duración adecuada del tratamiento, siguen siendo objetivo de estudio de los ensayos clínicos en curso. Como médicos clínicos, creemos que las potentes propiedades antiinflamatorias de los esteroides sintéticos están bien definidas, y aún falta evidencia definitiva de que otras estrategias antiinflamatorias proporcionen una mejor eficacia, al menos en el COVID-19. Aunque los esteroides sintéticos comparten una marcada acción antiinflamatoria y escasos efectos mineralocorticoides, su bioequivalencia y diferentes cinéticas deben considerarse cuidadosamente, debido a la elevada variabilidad de la farmacocinética individual, uso y prescripción adecuada de estos fármacos, ya que pueden desencadenar efectos adversos diversos que podrían impactar negativamente el curso clínico del paciente con COVID-19. Además, muchos de los fármacos actualmente considerados en el manejo del paciente con esta patología pueden potenciar la vida media y la aparición de efectos adversos de los corticoesteroides, o algunos efectos adversos de estos otros fármacos pueden simular complicaciones asociadas al uso de corticoesteroides, lo que podría conllevar a una suspensión precoz e inoportuna de los mismos. Números estudios clínicos y artículos basados en revisiones narrativas han servido de guías para los médicos clínicos en medio de esta pandemia, sin embargo, sus resultados deben interpretarse con cautela. Por estas razones, hemos realizado un análisis con base en el sistema GRADE de estos estudios para contrastar la información incluida en los estudios clínicos y minimizar el error de análisis(AU)

e specific mechanism by which steroids would act on sustained lung inflammation, as well as the definition of the best drug to use and the appropriate treatment duration remain to be the objectives of ongoing clinical trials. As clinicians, we believe that the potent anti-inflammatory properties of synthetic steroids are well defined and definitive evidence that other anti-inflammatory strategies provide better efficacy is still lacking, at least in COVID-19. Although synthetic steroids share a pronounced anti-inflammatory action and few mineralocorticoid effects, their bioequivalence and different kinetics should be considered, due to the high variability of individual pharmacokinetics, the appropriate use and prescription of these drugs, given that they could trigger various effects that could negatively impact the clinical course of the patient with COVID-19. In addition, many of the drugs currently considered in the management of the patient with this disease can enhance the half-life and appearance of adverse effects of corticosteroids and some adverse effects of these other drugs can simulate complications associated with the use of corticosteroids, which could lead to an early and untimely suspension of them. Numerous clinical studies and study articles based on narrative reviews have served as guides for clinicians in the midst of this pandemic; however, the results of these should be interpreted with caution. For these reasons, we have performed an analysis based on the GRADE system of these studies to contrast the information included in the clinical studies and minimize the error of analysis(AU)

Biodynamics of mercury in mussel tissues as a function of exposure pathway: natural vs microplastic routes.

In the marine environment, metals can be present dissolved or adsorbed to suspended particles. In the last decades a new type of particle has been introduced, microplastics (MPs). The exposure route of pollutants influences their accumulation and distribution into tissues. A pulse-chase experiment was conducted in which mussels were exposed to Hg: adsorbed onto MPs and microalgae (MA) and dissolved (WB). Mussels accumulated the same amount of Hg independently of particle, due to the Hg loading in both particles and their acceptability were similar. The highest Hg accumulation occurred in gill when the Hg exposure was through water and in digestive gland when Hg was adsorbed to particles. More than 70% of the Hg uptake through MPs was quickly eliminated due to: i) part of the cleared MPs might not really be ingested but adhered to body surfaces of mussels, ii) MPs ingested were eliminated through faeces as they are non-nutritive particles which may be rejected in stomach preventing their entry into digestive gland and iii) high affinity of Hg on surface of MPs which meant that Hg was mainly eliminated jointly to MPs. The organic nature of MA facilitates the entry of Hg into digestive gland where MA are intracellularly digested releasing the Hg adsorbed onto their surfaces. In this case, Hg may reach deeper levels by translocation of the Hg incorporated into gland towards foot and remaining tissues, a process that might occur through haemolymph. All of the Hg accumulated in WB during the exposure was internally absorbed into tissues, and later translocated from gill to gland. Although Hg elimination rate in MPs mussels was greater than in the other exposure pathways, an important amount of Hg was maintained through the depuration period, thus we cannot and should not neglect the risk of MPs as vectors for mercury.

Ameliorative effect of black grape juice on systemic alterations and mandibular osteoradionecrosis induced by whole brain irradiation in rats.

PURPOSE: Whole brain irradiation (WBI) causes a variety of secondary side-effects including anorexia and bone necrosis. We evaluated the radiomodifying effect of black grape juice (BGJ) on WBI alterations in rats measuring food and water intake, body weight, hemogram, and morphological and histological mandibular parameters. MATERIALS AND METHODS: Forty male rats (200-250 g) were exposed to eight sessions of cranial X-ray irradiation. The total dose absorbed was 32 Gy delivered over 2 weeks. Four groups were defined: (i) NG: non-irradiated, glucose and fructose solution-supplemented (GFS); (ii) NJ: non-irradiated, BGJ-supplemented; (iii) RG: irradiated, GFS-supplemented; and (iv) RJ: irradiated, BGJ-supplemented. Rats received daily BGJ or GFS dosing by gavage starting 4 days before, continuing during, and ending 4 days after WBI. RESULTS: RJ rats ingested more food and water and showed less body weight loss than RG rats during the irradiation period. Forty days after WBI, irradiated animals started losing weight again compared with controls as a consequence of masticatory hypofunction by mandibular osteoradionecrosis (ORN). Osteoclastic activity and inflammation were apparent in RG rat mandibles. BGJ was able to attenuate the severity of ORN as well as to improve white and red blood cell counts. CONCLUSIONS: Fractionated whole brain irradiation induces mandibular changes that interfere with normal feeding. BGJ can be used to mitigate systemic side-effects of brain irradiation and ORN.

Actuación farmacéutica en el control de la duración del tratamiento con antimicrobianos en el ámbito hospitalario - Respuesta de los autores / Pharmaceutical intervention in duration of antimicrobial treatment at hospital ambit - Author´s response

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Actuación farmacéutica en el control de la duración del tratamiento con antimicrobianos en el ámbito hospitalario / Pharmaceutical intervention in duration of antimicrobial treatment at hospital ambit

Objetivo. Estimar el grado de aceptación de la actuación farmacéutica en el control de la duración del tratamiento antimicrobiano. Valorar su impacto en la optimización del uso de antibióticos. Método. Estudio prospectivo observacional realizado durante dos años en un Hospital General Universitario. Se efectuó un seguimiento de pacientes adultos no críticos con tratamiento antibiótico. Cuando la duración del tratamiento no se adecuó a unos criterios establecidos por antibiótico y patología, se realizó una comunicación con el médico, en la que se recomendó valorar la necesidad de continuar con el tratamiento. Se registró la aceptación de la intervención y se analizó el impacto, mediante el consumo en antimicrobianos e incidencia de Clostridium difficile. Resultados. En 122 pacientes se realizó una actuación farmacéutica por tratamiento antibiótico prolongado. Los antibióticos más prevalentes fueron β-lactámicos, concretamente el meropenem. La vía de administración intravenosa fue más frecuente. En 77 casos se decidió recomendar la suspensión del tratamiento, se llevó a cabo una intervención prospectiva de forma oral en el 70,15% y el resto escrita. La aceptación fue del 65,95% y del 65,00%, respectivamente. Durante el periodo de estudio, las DDD disminuyeron un 8,89% y el gasto en antimicrobianos un 40,12%. La incidencia de C. difficile se mantuvo estable. Conclusiones. En un entorno hospitalario, un programa de asesoramiento farmacéutico sobre la duración del tratamiento antimicrobiano tiene buena aceptación por parte del prescriptor, aunque mejorable. La vía de información no afecta al grado de aceptación. Este tipo de actuaciones podría implicar una reducción del consumo antimicrobiano (AU)

Objective. To estimate the acceptance of the pharmaceutical intervention in controlling duration of antimicrobial therapy and to evaluate their impact on optimizing the treatment. Methods. Prospective observational study for two years in a General University Hospital. For the patients record, we followed non critical adult patients with antibiotic treatment. When the duration of antimicrobial treatment not complied with established criteria for each antibiotic and pathology, there was a communication with the physician, at which is recommended to assess the need for continue treatment. The acceptance of pharmaceutical intervention was collected and afterwards we analyzed the impact of this work by antimicrobial consumption and incidence of Clostridium difficile. Results. In 122 patients the pharmacist made a pharmaceutical intervention due to prolonged antibiotic treatment. The most prevalent antibiotics were β-lactams, specifically meropenem. The intravenous administration was more frequent. In 77 cases it was decided to recommend the suspension of treatment, we conducted an orally prospective intervention at 70.15 % and the rest of interventions were written. Acceptance was 65.95 % and 65.00%, respectively. During the study period, the DDD of the antimicrobials decreased by 8.89% and expenditure on antimicrobials one 40.12%. The incidence of C. difficile was stable. Conclusions. In a hospital, a pharmaceutical counselling program on the duration of antimicrobial therapy is well accepted by the prescriber physician, but it must be improved. The route of information does not affect the degree of acceptance. These actions could involve a reduction of antimicrobial consumption (AU)

Reduced seed predation after invasion supports enemy release in a broad biogeographical survey.

The Enemy Release (ER) hypothesis predicts an increase in the plant invasive capacity after being released from their associated herbivores or pathogens in their area of origin. Despite the large number of studies on biological invasions addressing this hypothesis, tests evaluating changes in herbivory on native and introduced populations and their effects on plant reproductive potential at a biogeographical level are relatively rare. Here, we tested the ER hypothesis on the South African species Senecio pterophorus (Asteraceae), which is native to the Eastern Cape, has expanded into the Western Cape, and was introduced into Australia (>70-100 years ago) and Europe (>30 years ago). Insect seed predation was evaluated to determine whether plants in the introduced areas were released from herbivores compared to plants from the native range. In South Africa, 25 % of the seedheads of sampled plants were damaged. Plants from the introduced populations suffered lower seed predation compared to those from the native populations, as expected under the ER hypothesis, and this release was more pronounced in the region with the most recent introduction (Europe 0.2 % vs. Australia 15 %). The insect communities feeding on S. pterophorus in Australia and Europe differed from those found in South Africa, suggesting that the plants were released from their associated fauna after invasion and later established new associations with local herbivore communities in the novel habitats. Our study is the first to provide strong evidence of enemy release in a biogeographical survey across the entire known distribution of a species.

Estrés traumático secundario: personalidad y sacudida de creencias / Secondary traumatic stress: personality and shattered assumptions

El trauma ha recibido una gran atención en los últimos años. Una línea de trabajo en el tema ha consistido en analizar la importancia de las variables personales en la resistencia y vulnerabilidad ante el trauma (Figley, 1995) y, como consecuencia, el efecto que dicho trauma tiene sobre el profesional (Stamm, 2003). Este trabajo empírico examina, en una muestra de 419 profesionales sanitarios, el papel de determinadas variables de personalidad (empatía, comprensibilidad, reto y sentido del humor) como moderadoras en la relación entre determinadas variables laborales (tarea traumática y sobrecarga laboral) y el cambio de creencias y valores sobre el mundo (Janoff-Bulman, 1992). La medida del síndrome se realiza a partir del Cuestionario de Estrés Traumático Secundario (Moreno et al., 2004). Los resultados indican que tales variables de personalidad parecen desempeñar un importante papel en el proceso de sacudida de creencias. Finalmente, la discusión enfatiza la necesidad de centrar la atención en la interacción entre los factores de personalidad y las demandas laborales y contextuales para avanzar en la compresión del proceso del trauma en trabajadores de emergencias

Trauma has received a great deal of attention in recent years. One line of research in this field focuses on the importance of personality variables in the resistance and vulnerability to trauma (Figley, 1995) and on the consequences of trauma on emergency professionals (Stamm, 2002). The purpose of this study was to examine in a sample of 419 emergency professionals the role of several personality variables (empathy, comprehensibility, challenge and sense of humor) as moderators of the relationship between job demands (traumatic task and overload) with shattered assumptions (Janoff-Bulman, 1992). Secondary traumatic stress was measured with measured with Secondary Traumatic Stress Measure (Moreno et al., 2004). Results indicate these personality variables seem to have an important role in the change of assumptions process. Finally, further implications of the finding are discussed

Id2 leaves the chromatin of the E2F4-p130-controlled c-myc promoter during hepatocyte priming for liver regeneration.

The Id (inhibitor of DNA binding or inhibitor of differentiation) helix-loop-helix proteins are involved in the regulation of cell growth, differentiation and cancer. The fact that the molecular mechanisms of liver regeneration are not completely understood prompted us to study the fate of Id2 in proliferating liver. Id2 increases in liver regeneration after partial hepatectomy, following the early induction of its gene. Co-immunoprecipitation shows that Id2 forms a complex with E2F4, p130 and mSin3A in quiescent liver and all these components are present at the c-myc promoter as shown using ChIP (chromatin immunoprecipitation). Activation of c-myc during hepatocyte priming (G0-G1 transition) correlates with the dissociation of Id2 and HDAC (histone deacetylase), albeit p130 remains bound at least until 6 h. Moreover, as the G0-G1 transition progresses, Id2 and HDAC again bind the c-myc promoter concomitantly with the repression of this gene. The time course of c-myc binding to the Id2 promoter, as determined by ChIP assays is compatible with a role of the oncoprotein as a transcriptional inducer of Id2 in liver regeneration. Immunohistochemical analysis shows that Id2 also increases in proliferating hepatocytes after bile duct ligation. In this case, the pattern of Id2 presence in the c-myc promoter parallels that found in regenerating liver. Our results may suggest a control role for Id2 in hepatocyte priming, through a p130 dissociation-independent regulation of c-myc.

Vitamin E deficiency induces liver nuclear factor-kappaB DNA-binding activity and changes in related genes.

The biological functions of vitamin E have been classically attributed to its property as a potent inhibitor of lipid peroxidation in cellular membranes. However, in 1991, Azzi's group first described that alpha-tocopherol inhibits smooth muscle cell proliferation in a protein kinase C (PKC)-dependent way, demonstrating a non-antioxidant cell signalling function for vitamin E. More recently, the capacity of alpha-tocopherol to modulate gene expression with the implication of different transcription factors, beyond its antioxidant properties, has also been established. This study was to determine the effect of vitamin E-deficiency on liver nuclear factor-kappa B (NF-kappaB) DNA-binding activity and the response of target antioxidant-defense genes and cell cycle modulators. Rats were fed either control diet or vitamin-E free diet until 60 or 90 days after birth. Vitamin E-deficiency enhanced liver DNA-binding activity of NF-kappaB [electrophoretic mobility-shift assay, (EMSA)] and up-regulated transcription of gamma-glutamylcysteine synthetase (gamma-GCSM; gamma-GCSC), cyclin D1 and cyclin E. We also showed down-regulation of p21(Waf1/Cip1) transcription. Western-blot analysis demonstrated that gamma-glutamylcysteine synthetase catalytic subunit (gamma-GCSC) and cyclin D1 showed a similar pattern to that found in the RT-PCR analysis. Moreover, chromatin immunoprecipitation (ChIP) assay demonstrated that NF-kappaB directly regulates transcription of gamma-GCS (both subunits) and cyclin D1 through the binding of NF-kappaB to the corresponding gene promoters, which was enhanced in vitamin E-deficiency. These findings show that vitamin E-deficiency induces significant molecular regulatory properties in liver cells with an altered expression of both antioxidant-defense genes and genes that control the cell cycle and demonstrate that liver NF-kappaB activation is involved in this response. Our results emphasize the importance of maintaining an adequate vitamin E consumption not only to prevent liver oxidative damage but also in modulating signal transduction.

Estrés traumático secundario: el coste de cuidar el trauma / No disponible

En los últimos años se ha ido elaborando un cuerpo teórico sobre los efectos del estrés en cuidadores, voluntarios y profesionales (Stamm, 1999). El planteamiento es "¿Quién cuida a los cuidadores?". Traumatización vicaria, desgaste por empatía o estrés traumático secundario son algunos de los términos usados para denominar los efectos de situaciones altamente estresantes o traumatizantes a las que tiene que asistir el personal sanitario, policías, psicólogos u otros profesionales involucrados en emergencias, desastres o en la atención general a cualquier tipo de víctimas. Los resultados de esta situación pueden llevar a la aparición de un estrés traumático secundario y a encontrar difícil la continuación de su trabajo. Las bases teóricas son recientes y están siendo propuestas desde 1995 por autores como Dutton, Figley, Janoff-Bulman, Stamm, etc. En este artículo se expone una visión global del tema y se presentan algunas reflexiones sobre los últimos modelos teóricos, además de la sintomatología y los efectos que este síndrome tiene en la salud de las personas (AU)

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Two mammalian glucosamine-6-phosphate deaminases: a structural and genetic study.

Glucosamine-6-phosphate deaminase (EC 3.5.99.6) is an allosteric enzyme that catalyzes the reversible conversion of D-glucosamine-6-phosphate into D-fructose-6-phosphate and ammonium. Here we describe the existence of two mammalian glucosamine-6-phosphate deaminase enzymes. We present the crystallographic structure of one of them, the long human glucosamine-6-phosphate deaminase, at 1.75 A resolution. Crystals belong to the space group P2(1)2(1)2(1) and present a whole hexamer in the asymmetric unit. The active-site lid (residues 162-182) presented significant structural differences among monomers. Interestingly the region with the largest differences, when compared with the Escherichia coli homologue, was found to be close to the active site. These structural differences can be related to the kinetic and allosteric properties of both mammalian enzymes.

In vivo studies of altered expression patterns of p53 and proliferative control genes in chronic vitamin A deficiency and hypervitaminosis.

Several clinical trials have revealed that individuals who were given beta-carotene and vitamin A did not have a reduced risk of cancer compared to those given placebo; rather, vitamin A could actually have caused an adverse effect in the lungs of smokers [Omenn, G.S., Goodman, G.E., Thornquist, M.D., Balmes, J., Cullen, M.R., Glass, A., Keogh, J.P., Meyskens, F.L., Valanis, B., Williams, J.H., Barnhart, S. & Hammar, S. N. Engl. J. Med (1996) 334, 1150-1155; Hennekens, C.H., Buring, J.E., Manson, J.E., Stampfer, M., Rosner, B., Cook, N.R., Belanger, C., LaMotte, F., Gaziano, J.M., Ridker, P.M., Willet, W. & Peto, R. (1996) N. Engl. J. Med. 334, 1145-1149]. Using differential display techniques, an initial survey using rats showed that liver RNA expression of c-H-Ras was decreased and p53 increased in rats with chronic vitamin A deficiency. These findings prompted us to evaluate the expression of c-Jun, p53 and p21WAF1/CIF1 (by RT-PCR) in liver and lung of rats. This study showed that c-Jun levels were lower and that p53 and p21WAF1/CIF1 levels were higher in chronic vitamin A deficiency. Vitamin A supplementation increased expression of c-Jun, while decreasing the expression of p53 and p21WAF1/CIF1. Western-blot analysis demonstrated that c-Jun and p53 showed a similar pattern to that found in the RT-PCR analyses. Binding of retinoic acid receptors (RAR) to the c-Jun promoter was decreased in chronic vitamin A deficiency when compared to control hepatocytes, but contrasting results were found with acute vitamin A supplementated cells. DNA fragmentation and cytochrome c release from mitochondria were analyzed and no changes were found. In lung, an increase in the expression of c-Jun produced a significant increase in cyclin D1 expression. These results may explain, at least in part, the conflicting results found in patients supplemented with vitamin A and illustrate that the changes are not restricted to lung. Furthermore, these results suggest that pharmacological vitamin A supplementation may increase the risk of adverse effects including the risk of oncogenesis.