Vaccination impact: mortality and time shift to COVID-19 maximum severity in hospitalized patients. An Argentine multicenter registry.

INTRODUCTION: The COVID-19 vaccine became an effective instrument to prevent severe SARS-CoV-2 infections. However, 5% of vaccinated patients will have moderate or severe disease. OBJECTIVE: to compare mortality and days between the symptom onset to the peak disease severity, in vaccinated vs. unvaccinated COVID-19 hospitalized patients. METHODS: Retrospective observational study in 36 hospitals in Argentina. COVID-19 adults admitted to general wards between January 1, 2021, and May 31, 2022 were included. Days between symptoms onset to peak of severity were compared between vaccinated vs. unvaccinated patients with Cox regression, adjusted by Propensity Score Matching (PSM). Results in patients with one and two doses were also compared. RESULTS: A total of 3663 patients were included (3001 [81.9%] unvaccinated and 662 [18%] vaccinated). Time from symptom onset to peak severity was 7 days (IQR 4-12) vs. 7 days (IQR 4-11) in unvaccinated and vaccinated. In crude Cox regression analysis and matched population, no significant differences were observed. Regarding mortality, a Risk Ratio (RR) of 1.51 (IC95% 1.29-1.77) was observed in vaccinated patients, but in the PSM cohort, the RR was 0.73 (IC95% 0.60-0.88). RR in patients with one COVID-19 vaccine dose in PSM adjusted population was 0.7 (IC95% 0.45-1.03), and with two doses 0.6 (IC95% 0.46-0.79). DISCUSSION: The time elapsed between the onset of COVID-19 symptoms to the highest severity was similar in vaccinated and unvaccinated patients. However, hospitalized vaccinated patients had a lower risk of mortality than unvaccinated patients.

Introducción: A pesar de la eficacia de la vacuna contra el COVID-19 el 5% de los pacientes vacunados presentaran una enfermedad moderada o grave. El objetivo del presente estudio fue comparar los días entre el inicio de los síntomas y la gravedad máxima de la enfermedad, en pacientes con COVID-19 vacunados vs. no vacunados. Métodos: Estudio observacional retrospectivo en 36 hospitales de Argentina. Se incluyeron adultos con COVID-19 hospitalizados entre el 1/01/2021 y 31/5/2022. Se recolectaron datos demográficos, comorbilidades y progresión clínica de la enfermedad. Se compararon los días entre el inicio de los síntomas y el pico de gravedad entre vacunados y no vacunados mediante regresión de Cox, ajustada por emparejamiento por Propensity Score Matching (PSM). En un análisis de subgrupos, se compararon los resultados en pacientes con una y dos dosis de vacuna. Resultados: Se incluyeron 3663 pacientes (3001 [81.9%] no vacunados y 662 [18%] vacunados). El tiempo transcurrido desde el inicio de los síntomas hasta el pico de gravedad fue de 7 días (IQR 4 - 12) en no vacunados, y de 7 días (IQR 4-11) en vacunados. Tanto en el análisis de regresión de Cox crudo como en el ajustado, no se observaron diferencias significativas entre ambos grupos (HR ajustado 1.08 [IC 95% 0.82-1.4; p = 0.56]). En cuanto a la mortalidad, el Riesgo Relativo (RR) fue 1.51 (IC95% 1.29-1.77) en los pacientes vacunados, pero en la cohorte ajustada por Propensity Score, el RR fue de 0.73 (IC95% 0.60-0.88). El RR en el grupo con una dosis de vacuna COVID-19 en el análisis PSM fue 0.7 (IC95% 0.45-1.03), y con dos dosis 0.6 (IC95% 0.46-0.79). Discusión: El tiempo entre el inicio de los síntomas de COVID-19 y el pico de severidad fue igual en vacunados y no vacunados. Sin embargo, los pacientes vacunados hospitalizados presentaron menor mortalidad tras el ajuste por confundidores.

[Syphilis: uncommon presentation forms]. / Sífilis: formas de presentación poco frecuentes.

Uncommon forms of syphilis exist, among which neurosyphilis, otosyphilis, and ocular syphilis are included. Neurosyphilis is the infection of the central nervous system caused by Treponema pallidum. The clinical manifestations of neurosyphilis are diverse and include early, late, and atypical forms. Syphilis can affect virtually any ocular structure and can occur at any stage of the disease, as well as otosyphilis. The diagnosis of these conditions is often challenging. However, it is important to consider them as a differential diagnosis, as most of these clinical manifestations are reversible with appropriate antibiotic treatment. A case series study of patients diagnosed with neurosyphilis, otosyphilis, and ocular syphilis, who were admitted to a tertiary-level hospital, is here presented: syphilitic meningitis with cranial nerve involvement, and seizures (case 1), ocular syphilis (case 2), general paresis (case 3), and tabes dorsalis (case 4). Half of the patients presented bilateral sensorineural hearing loss; and also half of the patients had reactive VDRL in cerebrospinal fluid. All were treated with aqueous penicillin G, and in two of these cases, ceftriaxone was chosen to complete ambulatory treatment. One patient had an unfavorable outcome and died (case 1); another was lost in follow-up (case 4); one completely resolved his symptoms (case 2); and another one experienced symptom relapse six months after treatment (case 3).

Existen formas de presentación poco frecuentes de sífilis, dentro de las cuales se incluyen la neurosífilis, otosífilis y sífilis ocular. La neurosífilis es la infección del sistema nervioso central por Treponema pallidum. Las manifestaciones clínicas de neurosífilis son variadas e incluyen formas tempranas, tardías y atípicas. Además, la sífilis puede comprometer prácticamente cualquier estructura ocular, en cualquier etapa de la enfermedad, como así también la otosífilis. El diagnóstico de estas entidades suele ser dificultoso. Sin embargo, resulta importante considerarlas como diagnósticos diferenciales, ya que la mayoría de estas manifestaciones son reversibles con tratamiento antibiótico adecuado. Se presenta una serie de casos de pacientes con diagnóstico de neurosífilis, otosífilis y sífilis ocular, que cursaron internación en un hospital de tercer nivel: meningitis sifilítica con compromiso de pares craneales y convulsiones (caso 1), sífilis ocular (caso 2), paresis general (caso 3) y tabes dorsalis (caso 4). La mitad de los pacientes presentó hipoacusia neurosensorial bilateral. El 50% presentó VDRL reactiva en líquido cefalorraquídeo. Todos fueron tratados con penicilina G sódica y en el 50% se optó por el uso de ceftriaxona como modalidad para finalizar el tratamiento en internación domiciliaria. Respecto a la evolución de los pacientes, uno de ellos falleció como consecuencia del cuadro de neurosífilis (caso 1), otro se perdió en el seguimiento (caso 4) mientras que, de los dos restantes, el caso 3 presentó recaída de su enfermedad a los 6 meses del tratamiento y el caso 2 resolvió ad integrum su sintomatología.

Papel de la persona navegadora del paciente en el cáncer de pulmón / The Role of the Navigator Person for a Patient with Lung Cancer

Introducción: la medicina basada en el valor ha logrado mejorar la calidad de atención del paciente y/o la satisfacción de las personas, reduciendo costos y obteniendo mejores resultados. Se apoya sobre tres pilares básicos: la medicina basada en la evidencia, la atención centralizada en el paciente, y la sustentabilidad. Sin embargo, existen pocas publicaciones sobre la estrategia de personas navegadoras para pacientes con cáncer de pulmón, que podrían ser una herramienta clave para brindar apoyo, asegurando que tengan acceso al conocimiento y los recursos necesarios a fin de completar la vía de atención clínica recomendada. Estado del arte: se trata de una intervención en salud cuyo objetivo principal es lograr vencer las barreras relacionadas con la atención (p. ej., logísticas, burocrático-administrativas, de comunicación y financieras) para poder mejorar la calidad y el acceso a la salud en el marco de la atención del cáncer. Estas personas cumplen un papel de guía para pacientes durante el proceso de diagnóstico y tratamiento activo. Su labor consiste en vincular al paciente con los proveedores clínicos, brindar un sistema de apoyo, asegurar un acompañamiento individualizado, garantizar que tengan acceso al conocimiento y a los recursos necesarios para completar el seguimiento y/o tratamiento adecuado. Discusión/Conclusión: indudablemente, es un elemento cada vez más reconocido en los programas de cáncer, centrado en el paciente y de alta calidad. Su implementación será de especial interés en la Unidad de Práctica Integrada para personas con cáncer de pulmón. (AU)

Introduction: Value-based medicine has succeeded in improving the quality of patient care and or patient satisfaction, reducing costs, and obtaining better outcomes. It rests on three fundamental pillars: evidence-based medicine, patient-centered care, and sustainability. However, there are few publications on the people navigator strategy for lung cancer patients, which could be a crucial tool for providing support, ensuring that they have access to the knowledge and resources needed to complete the recommended clinical care pathway. State of the art: It is a health intervention whose main objective is to overcome care-related barriers (e.g., logistical, bureaucratic-administrative, communication, and financial) to improve quality and access to health in the context of cancer care. These individuals play a guiding role for patients during the diagnostic and active treatment process. Their job is to link the patient with clinical providers, provide a support system, ensure individualized accompaniment, and guarantee that they get access to the knowledge and resources necessary to complete the appropriate follow-up and, or treatment. Discussion/Conclusion: Undoubtedly, patient navigators represent an increasingly recognized element of high-quality, patient-centered cancer programs. Its implementation will be of specific interest in the Integrated Practice Unit for people with lung cancer. (AU)

Development and validation of COEWS (COVID-19 Early Warning Score) for hospitalized COVID-19 with laboratory features: A multicontinental retrospective study.

Background: The emergence of new SARS-CoV-2 variants with significant immune-evasiveness, the relaxation of measures for reducing the number of infections, the waning of immune protection (particularly in high-risk population groups), and the low uptake of new vaccine boosters, forecast new waves of hospitalizations and admission to intensive care units. There is an urgent need for easily implementable and clinically effective Early Warning Scores (EWSs) that can predict the risk of complications within the next 24-48 hr. Although EWSs have been used in the evaluation of COVID-19 patients, there are several clinical limitations to their use. Moreover, no models have been tested on geographically distinct populations or population groups with varying levels of immune protection. Methods: We developed and validated COVID-19 Early Warning Score (COEWS), an EWS that is automatically calculated solely from laboratory parameters that are widely available and affordable. We benchmarked COEWS against the widely used NEWS2. We also evaluated the predictive performance of vaccinated and unvaccinated patients. Results: The variables of the COEWS predictive model were selected based on their predictive coefficients and on the wide availability of these laboratory variables. The final model included complete blood count, blood glucose, and oxygen saturation features. To make COEWS more actionable in real clinical situations, we transformed the predictive coefficients of the COEWS model into individual scores for each selected feature. The global score serves as an easy-to-calculate measure indicating the risk of a patient developing the combined outcome of mechanical ventilation or death within the next 48 hr.The discrimination in the external validation cohort was 0.743 (95% confidence interval [CI]: 0.703-0.784) for the COEWS score performed with coefficients and 0.700 (95% CI: 0.654-0.745) for the COEWS performed with scores. The area under the receiver operating characteristic curve (AUROC) was similar in vaccinated and unvaccinated patients. Additionally, we observed that the AUROC of the NEWS2 was 0.677 (95% CI: 0.601-0.752) in vaccinated patients and 0.648 (95% CI: 0.608-0.689) in unvaccinated patients. Conclusions: The COEWS score predicts death or MV within the next 48 hr based on routine and widely available laboratory measurements. The extensive external validation, its high performance, its ease of use, and its positive benchmark in comparison with the widely used NEWS2 position COEWS as a new reference tool for assisting clinical decisions and improving patient care in the upcoming pandemic waves. Funding: University of Vienna.

Prevalence of the use of antidepressants in patients with venous thromboembolism / Prevalencia del uso de antidepresivos en pacientes con enfermedad tromboembólica venosa.

OBJECTIVE: To estimate the prevalence of Antidepressant use in patients with a history of venous thromboembolism (VTE). Describe the patient's characteristics and which drugs are the most prescribed. METHODS: A cross-sectional study involving a consecutive sample of patients included in the Registro de Enfermedad Tromboembólica (RIET) from the Hospital Italiano de Buenos Aires in a period between 01/01/2014 to 01/09/2018. All patients presented symptomatic VTE and confirmed diagnosis. Drugs considered included in this study were: Selective Serotonin Reuptake Inhibitors (SSRI), Dopamine and Norepinephrine Reuptake Inhibitors (NDRI), Serotonin and Norepinephrine Reuptake Inhibitors (SNRI) and Tricyclic antidepressants (TCA). RESULTS: From a total of 2373 patients with VTE, 472 were active users of antidepressants, showing a prevalence of antidepressant use of 19.9% (CI 95%). The most frequently prescribed drugs by drug classification were: SSRI 83.9%, TCA 20.5%, ISRN 14.6%, and NDRI 2.5%. Patients presented a median age of 76 years, predominantly women (71.4%), with several comorbidities: 52.24% arterial hypertension, 37.29% overweight, and 34.75% history of smoking. Concerning relevant history, we observed: 29.03% active oncologic disease, 26.27% major surgery before the VTE, and 21.61% previous VTE. CONCLUSION: The prevalence of antidepressant use in patients with VTE is 19.9%, superior by far to that of the general population. Depression is a major cause of morbidity worldwide, and its prevalence is increasing over the years.

OBJETIVOS: Estimar la prevalencia de consumo de fármacos antidepresivos en pacientes que hayan sufrido un evento tromboembólico venoso (TEV), describir esta población y las drogas más utilizadas. MATERIAL Y MÉTODOS: Corte transversal que incluyó una muestra consecutiva de adultos incluidos en el Registro de Enfermedad Tromboembólica (RIET) del Hospital Italiano de Buenos Aires entre el 01/01/2014 y el 1/09/2018. Se consideraron los siguientes fármacos: Inhibidores Selectivos de la Recaptación de Serotonina (IRSS), Inhibidores de la Recaptación de Dopamina y Noradrenalina (IRDN), Inhibidores de la Recaptación de Serotonina y Noradrenalina (IRSN), y Antidepresivos Tricíclicos (ATC). RESULTADOS: De un total de 2373 pacientes, 472 se identificaron como usuarios activos de antidepresivos, arrojando una prevalencia de 19,9% (IC95% de 18,3-21,6). Según familia farmacológica, en orden de mayor a menor frecuencia, se indicaron: IRSS 83,9%, ATC 20,5%, IRS 14,6% e IRDN y IRDN 2,5%. Los pacientes bajo tratamiento con antidepresivos presentaron una mediana de edad de 76 años, mayoritariamente mujeres (71,4%), con alta carga de comorbilidad: 52,24% hipertensión arterial, 37,29% sobrepeso, 34,75% ex tabaquismo. Los antecedentes de mayor frecuencia resultaron enfermedad oncológica activa (29,03%), cirugía mayor en último mes (26,27%), y el 21,61% presentaba ETV previa. CONCLUSIONES: La prevalencia de uso de antidepresivos en pacientes con ETV resultó 19,9%, superior a la población general. La depresión es una causa principal de enfermedad y discapacidad en todo el mundo, cuya prevalencia aumentó durante los últimos años.

Efecto de la inactivación de las órdenes múltiples para solicitud de estudios complementarios en una central de emergencias.

Introducción. La plantilla de órdenes múltiples es una herramienta informática que podría producir consecuencias inadvertidas pese a sus innumerables beneficios. Nos propusimos explorar el efecto de su inactivación sobre las solicitudes de estudios complementarios y los costos asociados. Métodos. Corte transversal en la Central de Emergencias de Adultos del Hospital Italiano de Buenos Aires, que incluyó muestra consecutiva de consultas pre-intervención (Enero-Febrero 2020) y post-intervención (2021). Mediante el uso de bases secundarias, las variables incluidas fueron los débitos administrativos y sus respectivos precios de facturación. Resultados. Hubo 27.671 consultas en 2020 con una mediana de valor total de 474$, y 20.819 con 1.639$ en 2021. Tras el análisis restringido al área de consultorios de moderada complejidad (excluyendo consultas por COVID-19), se encontró: una disminución en la mediana del número de prácticas por consulta (mediana de 11 vs 10, p=0,001), una disminución en la solicitud de al menos una práctica de laboratorio (45% versus 39%, p=0,001), sin encontrar cambios significativos en costos globales (mediana 1.419$ vs 1.081$; p=0,122) ni en costos específicos de laboratorio (mediana 1.071$ vs 1.089$, p=0,710). Conclusión. Pese a la inflación interanual, se logró una reducción significativa en el número de prácticas y se mantuvieron los costos globales por consulta. Estos hallazgos demuestran la efectividad de la intervención, pero serán necesarias medidas educativas que apunten al recordatorio de los potenciales daños en la sobreutilización, y los costos sanitarios de los estudios innecesarios.

COVID-19 vaccines reduce mortality in hospitalized patients with oxygen requirements: Differences between vaccine subtypes. A multicontinental cohort study.

The aim of this study was to analyze whether the coronavirus disease 2019 (COVID-19) vaccine reduces mortality in patients with moderate or severe COVID-19 disease requiring oxygen therapy. A retrospective cohort study, with data from 148 hospitals in both Spain (111 hospitals) and Argentina (37 hospitals), was conducted. We evaluated hospitalized patients for COVID-19 older than 18 years with oxygen requirements. Vaccine protection against death was assessed through a multivariable logistic regression and propensity score matching. We also performed a subgroup analysis according to vaccine type. The adjusted model was used to determine the population attributable risk. Between January 2020 and May 2022, we evaluated 21,479 COVID-19 hospitalized patients with oxygen requirements. Of these, 338 (1.5%) patients received a single dose of the COVID-19 vaccine and 379 (1.8%) were fully vaccinated. In vaccinated patients, mortality was 20.9% (95% confidence interval [CI]: 17.9-24), compared to 19.5% (95% CI: 19-20) in unvaccinated patients, resulting in a crude odds ratio (OR) of 1.07 (95% CI: 0.89-1.29; p = 0.41). However, after considering the multiple comorbidities in the vaccinated group, the adjusted OR was 0.73 (95% CI: 0.56-0.95; p = 0.02) with a population attributable risk reduction of 4.3% (95% CI: 1-5). The higher risk reduction for mortality was with messenger RNA (mRNA) BNT162b2 (Pfizer) (OR 0.37; 95% CI: 0.23-0.59; p < 0.01), ChAdOx1 nCoV-19 (AstraZeneca) (OR 0.42; 95% CI: 0.20-0.86; p = 0.02), and mRNA-1273 (Moderna) (OR 0.68; 95% CI: 0.41-1.12; p = 0.13), and lower with Gam-COVID-Vac (Sputnik) (OR 0.93; 95% CI: 0.6-1.45; p = 0.76). COVID-19 vaccines significantly reduce the probability of death in patients suffering from a moderate or severe disease (oxygen therapy).

Effect of computerized physician order entry inactivation to order complementary studies in an emergency department / [Efecto de la inactivación de las órdenes múltiples para solicitud de estudios complementarios en una central de emergencias.]

Introduction: The computerized provider order entry (CPOE) is a computing tool that could lead to unintended consequences despite its myriad benefits. We aimed to explore the effect of its inactivation on requests for complementary studies and the associated costs. Methods: Cross sectional study at the Emergency Department of Hospital Italiano de Buenos Aires, which included a consecutive sample of pre-intervention (January-February 2020) and post-intervention (2021) consultations. Using secondary bases, the variables included were administrative debits and their respective billing prices. Results: There were 27,671 consultations in 2020 with a total median value of $474, and 20,819 with $1,639 in 2021. After the analysis restricted to the area of ​​moderately complex clinics (excluding COVID-19 consultations), the following was found: a decrease in the median number of practices per consultation (median of 11 vs. 10, p=0.001), a decrease in the request for at least one laboratory practice (45% vs. 39%, p=0.001), without finding significant changes in global costs (median $1,419 vs. $1,081; p=0.122) or in specific laboratory costs (median $1,071 vs. $1,089, p=0.710). Conclusion: Despite inflation, a significant reduction in the number of practices was achieved and overall costs per consultation were maintained. These findings demonstrate the effectiveness of the intervention, but an educational intervention aimed at reminding the potential harm of overuse and the health costs of unnecessary studies will be necessary.

Introducción: La plantilla de órdenes múltiples es una herramienta informática que podría producir consecuencias inadvertidas pese a sus innumerables beneficios. Nos propusimos explorar el efecto de su inactivación sobre las solicitudes de estudios complementarios y los costos asociados. Métodos: Corte transversal en la Central de Emergencias de Adultos del Hospital Italiano de Buenos Aires, que incluyó muestra consecutiva de consultas pre-intervención (Enero-Febrero 2020) y post-intervención (2021). Mediante el uso de bases secundarias, las variables incluidas fueron los débitos administrativos y sus respectivos precios de facturación. Resultados: Hubo 27.671 consultas en 2020 con una mediana de valor total de 474$, y 20.819 con 1.639$ en 2021. Tras el análisis restringido al área de consultorios de moderada complejidad (excluyendo consultas por COVID-19), se encontró: una disminución en la mediana del número de prácticas por consulta (mediana de 11 vs 10, p=0,001), una disminución en la solicitud de al menos una práctica de laboratorio (45% versus 39%, p=0,001), sin encontrar cambios significativos en costos globales (mediana 1.419$ vs 1.081$; p=0,122) ni en costos específicos de laboratorio (mediana 1.071$ vs 1.089$, p=0,710). Conclusión: Pese a la inflación interanual, se logró una reducción significativa en el número de prácticas y se mantuvieron los costos globales por consulta. Estos hallazgos demuestran la efectividad de la intervención, pero serán necesarias medidas educativas que apunten al recordatorio de los potenciales daños en la sobreutilización, y los costos sanitarios de los estudios innecesarios.

Decrease in Mortality from Sepsis: Impact of the Multidisciplinary Program for the Hematologic Patient at Very High Risk.

A program for the hematologic patient at very high risk of infections (HAR, from its initials in Spanish) was implemented, based on a multidisciplinary team and six measures intended to reduce the colonization and subsequent sepsis by multidrug-resistant organisms (MDRO). We aimed at evaluating the effectiveness of the HAR program in terms of MDRO infections mainly caused by Klebsiella pneumoniae carbapenemase-producing and multidrug-resistant Pseudomona aeruginosa, and sepsis-related mortality. We established retrospective comparisons between the pre-HAR period (2016-2018) and the post-HAR period (2018-2019), in patients who received a hematopoietic stem cell transplant (HSCT) and/or intensive chemotherapy to treat non-M3 acute myeloid leukemia (CH-AML). We included 262 patients: 176 pre-HAR and 86 post-HAR. MDRO infection was 4.6% at 30 days and 6.1% at 90 days (all the cases during the pre-HAR period). Sepsis-related mortality was 6.5%, considering a median follow-up of 608 days: 6.1% in the HSCT group and 12.4% in the CH-AML group (p = 0.306). Sepsis-related mortality was 8.7% in the pre-HAR period and 0% in the post-HAR period (p = 0.014). The implementation of this multidisciplinary program based in preventive measures and the appropriate use of antibiotics enabled a decrease in sepsis-related mortality in very high-risk hematologic patients.

[Position of the international forum of internal medicine on habits, lifestyle changes and a healthy environment for the prevention of cardiovascular diseases]. / Posicionamiento del foro Internacional de Medicina Interna sobre Hábitos, modificaciones del Estilo de Vida y Ambiente Saludable para la Prevención de Enfermedades Cardiovasculares.

Cardiovascular diseases (CVD), mainly ischemic heart disease and stroke, is the main cause of death worldwide and each year more people die from CVD than from any other cause. These data call for a paradigm shift, where health promotion and cardiovascular prevention will acquire a central role in health policies. From this perspective, dedicating time during the consultation to promoting the acquisition of heart-healthy habits would be indicated in all individuals, regardless of cardiovascular risk classification, the role of the internist being fundamental. This position document from the International Forum of Internal Medicine (FIMI) presents the main indications regarding changes in lifestyle and acquisition of healthy habits to prevent CVD. The different sections will address topics including: nutrition, physical activity, sedentary lifestyle, obesity, smoking, alcohol consumption, sleep, stress, environmental problems related to CVD and specific conditions in women. A section is included about starting CVD promotion and prevention measures at an early age, childhood and adolescence, also mentioning epigenetic aspects related to CVD. Social determinants in CVD are also taken into account, since some of these aspects, such as low socioeconomic level, modify cardiovascular risk and should be taken into account.

Las enfermedades cardiovasculares (ECV), principalmente la cardiopatía isquémica y el accidente cerebrovascular (ACV), constituyen la principal causa de muerte a nivel mundial y cada año mueren más personas por ECV que por cualquier otra causa. Estos datos requieren la necesidad de un cambio de paradigma, en donde la promoción de la salud y la prevención cardiovascular adquieran un papel central en las políticas sanitarias. Desde esta perspectiva, dedicar tiempo durante la consulta en promocionar la adquisición de hábitos cardiosaludables estaría indicado en todos los individuos, independientemente de la clasificación de riesgo cardiovascular, siendo fundamental el rol del médico internista en su función de médico de cabecera. En este documento de posicionamiento del Foro Internacional de Medicina Interna (FIMI) se presentan algunas pautas para recomendar e indicar modificaciones en el estilo de vida y adquisición de hábitos saludables para prevenir la ECV, que tienen el objetivo de ser una herramienta practica para el médico internista. Las diferentes secciones abordaran temas que incluyen: nutrición, actividad física, sedentarismo, obesidad, hábito tabáquico, consumo de alcohol, sueño, estrés, problemas ambientales relacionados a la ECV y condiciones específicas en la mujer. Se incluyó un apartado acerca de comenzar las medidas de promoción y prevención de ECV en edades tempranas, infancia y adolescencia, mencionando además aspectos epigenéticos relacionados a la ECV. Se tienen en cuenta además los determinantes sociales en ECV, ya que algunos de estos aspectos, como el bajo nivel socioeconómico, modifican el riesgo cardiovascular y debieran ser tenidos en cuenta.

Position of the international forum of internal medicine on habits, lifestyle changes and a healthy environment for the prevention of cardiovascular diseases.

Cardiovascular diseases (CVD), mainly ischemic heart disease and stroke, is the main cause of death worldwide and each year more people die from CVD than from any other cause. These data call for a paradigm shift, where health promotion and cardiovascular prevention will acquire a central role in health policies. From this perspective, dedicating time during the consultation to promoting the acquisition of heart-healthy habits would be indicated in all individuals, regardless of cardiovascular risk classification, the role of the internist being fundamental. This position document from the International Forum of Internal Medicine (FIMI) presents the main indications regarding changes in lifestyle and acquisition of healthy habits to prevent CVD. The different sections will address topics including: nutrition, physical activity, sedentary lifestyle, obesity, smoking, alcohol consumption, sleep, stress, environmental problems related to CVD and specific conditions in women. A section is included about starting CVD promotion and prevention measures at an early age, childhood and adolescence, also mentioning epigenetic aspects related to CVD. Social determinants in CVD are also taken into account, since some of these aspects, such as low socioeconomic level, modify cardiovascular risk and should be taken into account.

Las enfermedades cardiovasculares (ECV), principalmente la cardiopatía isquémica y el accidente cerebrovascular (ACV), constituyen la principal causa de muerte a nivel mundial y cada año mueren más personas por ECV que por cualquier otra causa. Estos datos requieren la necesidad de un cambio de paradigma, en donde la promoción de la salud y la prevención cardiovascular adquieran un papel central en las políticas sanitarias. Desde esta perspectiva, dedicar tiempo durante la consulta en promocionar la adquisición de hábitos cardiosaludables estaría indicado en todos los individuos, independientemente de la clasificación de riesgo cardiovascular, siendo fundamental el rol del médico internista en su función de médico de cabecera. En este documento de posicionamiento del Foro Internacional de Medicina Interna (FIMI) se presentan algunas pautas para recomendar e indicar modificaciones en el estilo de vida y adquisición de hábitos saludables para prevenir la ECV, que tienen el objetivo de ser una herramienta practica para el médico internista. Las diferentes secciones abordaran temas que incluyen: nutrición, actividad física, sedentarismo, obesidad, hábito tabáquico, consumo de alcohol, sueño, estrés, problemas ambientales relacionados a la ECV y condiciones específicas en la mujer. Se incluyó un apartado acerca de comenzar las medidas de promoción y prevención de ECV en edades tempranas, infancia y adolescencia, mencionando además aspectos epigenéticos relacionados a la ECV. Se tienen en cuenta además los determinantes sociales en ECV, ya que algunos de estos aspectos, como el bajo nivel socioeconómico, modifican el riesgo cardiovascular y debieran ser tenidos en cuenta.

Consultorio de Salud Ambiental en un Hospital Privado de Comunidad de la Ciudad de Buenos Aires / Environmental Health consulting office in a Private Community Hospital of the Buenos Aires City

En los últimos años surge el concepto de Una Sola Salud que reconoce la interdependencia sistémica al observar que los cambios en la salud humana se expresan de manera sincrónica e indivisible de la salud del ambiente. Nuevas enfermedades y daños crónicos inespecíficos ocurren a la par de la pérdida de biodiversidad y vitalidad. En las últimas décadas venimos observando el surgimiento de "adaptaciones sistémicas" que requieren un abordaje desde la clínica y la toxicología a nivel individual y desde la epidemiología de la complejidad a nivel poblacional. Luego de un largo recorrido de investigaciones, el Hospital Italiano formalizó el consultorio de Salud Ambiental con la intención de brindar respuesta a la demanda de pacientes que atribuyen síntomas y signos a la polución ambiental. (AU)

In recent years, the concept of One Health has emerged, recognizing the systemic interdependence and the changes in human health that are expressed synchronously and indivisible from the environment. New diseases and nonspecific chronic damage are occuring in parallel with the loss of biodiversity and vitality.In recent decades we have observed the appearance of "systemic adaptations" that require a clinical and toxicological approach at the individual level, and address the population level from an epidemiological and complexity science paradigm. After many years of research, the Hospital Italiano de Buenos Aires formalized the Environmental Health consulting office and the measurement of glyphosate levels, giving answer to the demand of patients who associate their signs and symptoms to environmental pollution. (AU)

Impact of COVID-19 Pandemic on Telehealth and In-Person Visits: Implications from an Emergency Department in Argentina.

Since Argentina's government declared a national emergency to combat the COVID-19 pandemic with a lockdown status, it has produced consequences on the healthcare system. We aimed to quantify the effect on the Emergency Department (ED) visits at Hospital Italiano de Buenos Aires. Our electronic health data showed that ED in-person visits declined 46% during the COVID-19 pandemic, from an overall of 176,370 visits during 2019 to 95,421 visits during 2020. Simultaneously, there was a telehealth visits boom when mandatory quarantine began (March 20, 2020): from a median of 12 daily in February 2020 to a median of 338 daily in April 2020; reaching a maximum daily peak of 1,132 on March 26 2020. For a while, teleconsultations replaced ED visits. Then, when face-to-face visits began to increase, teleconsultations began to decrease slowly, as the phenomenon reversed.

Using Informatics Framework in Immunosuppressed or Transplanted Patients for a Preferential Care Route at the Emergency Department.

For immunosuppressed or transplanted patients, appropriate triage is a timely topic, especially in the Emergency Department (ED) of a high-volume referral center. We implemented a new Program called Rapid Clinical Care by Internal Medicine Specialists, as a preferential care route for these patients, which combines the proposed informatics framework in the field of total quality management in the healthcare units, as an example of digital technologies that can improve processes in the clinical routine. Our study aimed to describe waiting-time and attention-time in ED and to explore the effect on patients' clinical outcomes after discharge. Findings were: shortened waiting time (median of 8 minutes versus 21, p<0.001), improved ED on-call time (median of 2 hours compared to 4, p<0.001), and greater follow-up after discharge, measured as 1-week scheduled-visits rate (69% with 95%CI 63-75; compared to 43% with 95%CI 35-51; p<0.001).

Development and evaluation of a machine learning-based in-hospital COVID-19 disease outcome predictor (CODOP): A multicontinental retrospective study.

New SARS-CoV-2 variants, breakthrough infections, waning immunity, and sub-optimal vaccination rates account for surges of hospitalizations and deaths. There is an urgent need for clinically valuable and generalizable triage tools assisting the allocation of hospital resources, particularly in resource-limited countries. We developed and validate CODOP, a machine learning-based tool for predicting the clinical outcome of hospitalized COVID-19 patients. CODOP was trained, tested and validated with six cohorts encompassing 29223 COVID-19 patients from more than 150 hospitals in Spain, the USA and Latin America during 2020-22. CODOP uses 12 clinical parameters commonly measured at hospital admission for reaching high discriminative ability up to 9 days before clinical resolution (AUROC: 0·90-0·96), it is well calibrated, and it enables an effective dynamic risk stratification during hospitalization. Furthermore, CODOP maintains its predictive ability independently of the virus variant and the vaccination status. To reckon with the fluctuating pressure levels in hospitals during the pandemic, we offer two online CODOP calculators, suited for undertriage or overtriage scenarios, validated with a cohort of patients from 42 hospitals in three Latin American countries (78-100% sensitivity and 89-97% specificity). The performance of CODOP in heterogeneous and geographically disperse patient cohorts and the easiness of use strongly suggest its clinical utility, particularly in resource-limited countries.

While COVID-19 vaccines have saved millions of lives, new variants, waxing immunity, unequal rollout and relaxation of mitigation strategies mean that the pandemic will keep on sending shockwaves across healthcare systems. In this context, it is crucial to equip clinicians with tools to triage COVID-19 patients and forecast who will experience the worst forms of the disease. Prediction models based on artificial intelligence could help in this effort, but the task is not straightforward. Indeed, the pandemic is defined by ever-changing factors which artificial intelligence needs to cope with. To be useful in the clinic, a prediction model should make accurate prediction regardless of hospital location, viral variants or vaccination and immunity statuses. It should also be able to adapt its output to the level of resources available in a hospital at any given time. Finally, these tools need to seamlessly integrate into clinical workflows to not burden clinicians. In response, Klén et al. built CODOP, a freely available prediction algorithm that calculates the death risk of patients hospitalized with COVID-19 (https://gomezvarelalab.em.mpg.de/codop/). This model was designed based on biochemical data from routine blood analyses of COVID-19 patients. Crucially, the dataset included 30,000 individuals from 150 hospitals in Spain, the United States, Honduras, Bolivia and Argentina, sampled between March 2020 and February 2022 and carrying most of the main COVID-19 variants (from the original Wuhan version to Omicron). CODOP can predict the death or survival of hospitalized patients with high accuracy up to nine days before the clinical outcome occurs. These forecasting abilities are preserved independently of vaccination status or viral variant. The next step is to tailor the model to the current pandemic situation, which features increasing numbers of infected people as well as accumulating immune protection in the overall population. Further development will refine CODOP so that the algorithm can detect who will need hospitalisation in the next 24 hours, and who will need admission in intensive care in the next two days. Equipping primary care settings and hospitals with these tools will help to restore previous standards of health care during the upcoming waves of infections, particularly in countries with limited resources.

Síndrome de vena cava superior: una serie de casos consecutivos en pacientes internados en un hospital terciario universitario / Superior vena cava syndrome: a consecutive case series of in-hospital patients in a tertiary teaching hospital

Introducción: el síndrome de vena cava superior resulta de la obstrucción del flujo sanguíneo a través de este vaso. Casi la totalidad de los casos en la actualidad se asocian con tumores malignos. Existen controversias acerca del manejo apropiado de este cuadro. Actualmente, las terapias endovasculares son consideradas de elección. Materiales y métodos: se recolectaron y describieron, a partir de datos de la historia clínica electrónica, los casos de pacientes mayores de 18 años internados ­de forma consecutiva, que desarrollaron el síndrome­ en el Hospital Italiano de Buenos Aires en 2021. Se constataron las características basales, los tratamientos recibidos y los desenlaces clínicos intrahospitaliarios de cada uno de ellos. Resultados: un total de cinco pacientes fueron incluidos en el presente estudio y seguidos durante su instancia intrahospitalaria. Todos los casos descriptos fueron secundarios a enfermedades oncológicas. La mayoría de los pacientes presentaron un cuadro de moderada gravedad según las escalas utilizadas. En cuatro de cinco pacientes se optó por terapias endovasculares y dos de ellos fallecieron durante la internación. Discusión: existen controversias respecto del tratamiento óptimo del síndrome de vena cava superior, y heterogeneidad en la práctica clínica. Los estudios futuros deberían centrarse en identificar a aquellos pacientes que más probablemente se beneficien de las estrategias terapéuticas endovasculares, anticoagulantes o antiagregantes. (AU)

Introduction: superior vena cava syndrome results from an obstruction of blood flow through this vessel. Currently, almost all cases are associated with malignancies. There are controversies about the optimal management of this syndrome. Endovascular therapies are considered the first-line therapy. Material and methods: we collected clinical, laboratory and pharmacological data from patients admitted at the Hospital Italiano de Buenos Aires, between January 1st and November 1st 2021 with a diagnosis o superior vein cava syndrome. Baseline characteristics, treatment strategies and clinical outcomes were recorded. Results: a total of five patients were included in the present study. All cases were malignancy-related. Most of the patientsdeveloped moderate symptoms. Four out of five patients were treated with endovascular therapies and two patients died during hospitalization. Discussion: controversies regarding optimal management of the superior vena cava syndrome remain. Future research should focus on identifying those patients who are most likely to benefit from endovascular, anticoagulant or antiplatelet therapeutic strategies. (AU)

Geriatric co-management and interdisciplinary transitional care reduced hospital readmissions in frail older patients in Argentina: results from a randomized controlled trial.

BACKGROUND: Hospitalization is a moment of extreme vulnerability for frail older adults. There is scarce evidence on the effectiveness of geriatric co-management or transitional care interventions in Latin America. AIMS: To assess whether geriatric co-management combined with an interdisciplinary transitional care intervention could reduce 30-day hospital readmission rate compared to usual care in hospitalized frail older patients in a tertiary hospital in Argentina. METHODS: Single-blinded randomized controlled trial. Usual care treatment arm: all procedures performed during hospitalization were overseen by a senior internal medicine specialist and complied with pre-defined protocols. Patients had access to specialist care if needed, as well as hospital-at-home or home-based primary care services after discharge. Intervention treatment arm: in addition to usual care, a geriatric co-management team performed a comprehensive geriatric assessment during hospitalization, provided tailored recommendations to minimize geriatric syndromes and planned transition of care. A health and social care counselor oversaw continuity of care in patients' homes after discharge. RESULTS: We included 120 participants in each of the intervention and usual care (control) arms. Thirty-day hospital readmissions were 47.7% lower in the intervention arm (18.3% vs 35.0%; P = 0.040); and emergency room visits within the first 6 months after discharge were 27.8% lower (43.3% vs 60.0%; P = 0.010). There was a non-statistically significant decrease in 6-month mortality in the intervention arm (25.0% vs 35.0%; P = 0.124). CONCLUSION: Geriatric co-management of frail older patients during hospitalization combined with an interdisciplinary transitional care intervention reduced 30-day hospital readmissions and emergency visits 6 months after discharge. TRIAL REGISTRATION NUMBER: Trial registration number: RENIS IS003081.

[Effect COVID-19 pandemic in an emergency department in Argentina]. / Concurrencia a una central de emergencias de Argentina durante la pandemia COVID-19.

The objective of this study was to reveal how the COVID-19 pandemic process affected the number of visits to an emergency department of a highly complex hospital located in the Ciudad Autónoma de Buenos Aires, to explore the characteristics and reasons for consultation. The monthly number of visits between January 2019 and December 2020 was analyzed. The data showed a strong decrease in the number of visits (176 370 in 2019 and 95 421 in 2020), with an abrupt drop after the lockdown disposal (In aprilshowed the maximum reduction: 77.1%), and the different stages are reflected in the evolution (a consequence of quarantine), yielding a global annual reduction of 45.9%. The number of patients admitted by ambulances increased (5.1% in 2019 to 10.4% in 2020; p < 0.05), and consequently, the number of patients in the more complex sector (area B 2019: 5.3%, 2020: 11.5%; p < 0.01), as well as unscheduled hospitalizations from 6.8% (95% CI 6.7-6.9) to 12.1% in 2020 (95%CI11.8-12.3), p < 0.01. The five most frequent reasons for consultation in 2020 were: fever (5.1%), odynophagia (4.7%), abdominal pain (2.6%), cough (1.8%) and headache (1.8%), probably all related to COVID-19. In conclusion, the number of emergency department visits decreased by half compared to the previous year.

El objetivo de este estudio fue revelar cómo el COVID-19 afectó el número de visitas a un servicio de urgencias de un hospital de alta complejidad ubicado en la Ciudad Autónoma de Buenos Aires, explorar las características y los motivos de consulta. Se analizó el número mensual entre enero 2019 y diciembre 2020. Los datos mostraron una fuerte disminución en el número de visitas (176 370 en 2019 y 95 421 en 2020), con una caída abrupta luego de disposición aislamiento social, preventivo y obligatorio (el mes de abril arrojó el máximo valor de reducción: 77.1%), y se reflejan las diferentes etapas evolutivas (consecuencia de la cuarentena), arrojando una reducción global anual del 45.9%. Sin embargo, aumentó el número de pacientes que ingresaron en ambulancias (5.1% en 2019 a 10.4% en 2020; p < 0.05), y, en consecuencia, los pacientes del sector de mayor complejidad (área B 2019: 5.3%, 2020: 11.5%; p < 0.01), y las hospitalizaciones no programadas de 6.8% (IC95% 6.7-6.9) a 12.1% en 2020 (IC95% 11.8-12.3), p < 0.01. Los cinco motivos de consulta más frecuentes durante 2020 resultaron: fiebre (5.1%), odinofagia (4.7%), dolor abdominal (2.6%), tos (1.8%) y cefalea (1.8%), probablemente todos relacionados a COVID-19. En conclusión, se redujo a la mitad el número de visitas a urgencias en comparación con el año previo.

[Descriptive analysis of 4776 patients admitted to medical clinic services for COVID-19. Results of the Argentine Multi-Center Registry - REMA-COVID-19]. / Análisis descriptivo de 4776 pacientes internados en servicios de clínica médica por COVID-19. Resultados del Registro Multicéntrico Argentino - REMA-COVID-19.

A multicenter registry that included adults hospitalized for COVID-19 was carried out in various provinces of Argentina, from March to October 2020. The objectives were to describe the epidemiological characteristics, clinical manifestations, treatments, complications and risk factors, need for admission to critical care units and mortality. The registry included information on 4776 patients in 37 health centers in Argentina. Of them, 70.2% came from the city of Buenos Aires and from Buenos Aires Province; 52.3% were men. The mean age was 56 years (SD 20.3). Of them, 13.1% stated that they were health personnel. The median time of symptoms at the time of hospitalization was 3 days (CI 1-6). The most frequent comorbidities were hypertension in 32.4% and diabetes mellitus in 15.8%. The most frequent symptoms were: cough 58%, odynophagia 23.3%, myalgia 20.5% and fever / low-grade fever 19.9%. The hospital stay had a median of 8 days (CI 4-15). A 14.8% of the patients required critical care, while 3.2% who also required it, were not transferred to a closed unit due to adequacy of the therapeutic effort. The most frequent complications in critical care were: cardiovascular events (54.1%), septic shock (33.3%), renal failure (9.7%) and pneumonia associated with mechanical ventilation (12.5%). Overall mortality was 12.3%. Old age, dementia and COPD behaved as independent predictors of mortality (p < 0.001, 0.007 and 0.002 respectively) in the multivariate analysis.

Se realizó un registro multicéntrico que incluyó personas adultas internadas por COVID-19 en varias provincias de la Argentina, desde marzo a octubre de 2020. Los objetivos fueron describir las características epidemiológicas, manifestaciones clínicas, tratamientos, complicaciones y factores de riesgo, necesidad de admisión a unidades de cuidados críticos y mortalidad. El registro incluyó información de 4776 pacientes, en 37 centros de salud de Argentina. El 70.2% provenían de la ciudad de Buenos Aires y la provincia de Buenos Aires. El 52.3% eran hombres. La media de edad fue de 56 años (DE 20.3). Un 13.1% de pacientes manifestó ser personal de salud. La mediana de tiempo de síntomas al momento de la internación fue de 3 días (IC 1-6). Las comorbilidades más frecuentes fueron hipertensión arterial en 32.4% y diabetes mellitus en 15.8%. Los síntomas más frecuentes fueron: tos 58%, odinofagia 23.3%, mialgias 20.5% y fiebre/febrícula 19.9%. La estadía hospitalaria tuvo una mediana de internación de 8 días (IC 4-15). El 14.8% de los pacientes requirió cuidados críticos, en tanto que el 3.2%, que también lo requería, no pasó a unidad cerrada por adecuación del esfuerzo terapéutico. Las complicaciones más frecuentes en cuidados críticos fueron: eventos cardiovasculares (54.1%), shock séptico (33.3%), insuficiencia renal (9.7%) y neumonía asociada a la ventilación mecánica (12.5%). La mortalidad global fue del 12.3%. La edad avanzada, demencia y EPOC se comportaron como predictores independientes de mortalidad (p < 0.001, 0.007 y 0.002 respectivamente) en el análisis multivariado.