How the COVID-19 pandemic affects the moral reasoning of pediatric residents and the general population.

BACKGROUND: Kohlberg's theory of moral development asserts that people progress through different stages of moral reasoning as their cognitive abilities and social interactions mature. Individuals at the lowest stage of moral reasoning (preconventional stage) judge moral issues based on self-interest, those with a medium stage (conventional stage) judge them based on compliance with rules and norms, and those at the highest stage (postconventional stage) judge moral issues based on universal principles and shared ideals. Upon attaining adulthood, it can be considered that there is stability in the stage of individuals' moral development; however, the effect of a global population crisis such as the one experienced in March 2020, when the World Health Organization (WHO) declared the COVID-19 pandemic, is unknown. The purpose of this study was to evaluate the changes in the moral reasoning of pediatric residents before and after one year of the COVID-19 pandemic and compare them with a general population group. METHODS: This is a naturalistic quasi-experimental study conducted with two groups, one comprised 47 pediatric residents of a tertiary hospital converted into a COVID hospital during the pandemic and another group comprised 47 beneficiaries of a family clinic who were not health workers. The defining issues test (DIT) was applied to the 94 participants during March 2020, before the pandemic initiated in Mexico, and later during March 2021. To assess intragroup changes, the McNemar-Bowker and Wilcoxon tests were used. RESULTS: Pediatric residents showed higher baseline stages of moral reasoning: 53% in the postconventional group compared to the general population group (7%). In the preconventional group, 23% were residents and 64% belonged to the general population. In the second measurement, one year after the start of the pandemic, the group of residents had a significant decrease of 13 points in the P index, unlike the general population group in which a decrease of 3 points was observed. This decrease however, did not equalize baseline stages. Pediatric residents remained 10 points higher than the general population group. Moral reasoning stages were associated with age and educational stage. CONCLUSIONS: After a year of the COVID-19 pandemic, we found a decrease in the stage of moral reasoning development in pediatric residents of a hospital converted for the care of patients with COVID-19, while it remained stable in the general population group. Physicians showed higher stages of moral reasoning at baseline than the general population.

Differences in moral reasoning among medical graduates, graduates with other degrees, and nonprofessional adults.

BACKGROUND: Reasoning and moral action are necessary to resolve day-to-day moral conflicts, and there are certain professions where a greater moral character is expected, e.g., medicine. Thus, it is desirable that medical students develop skills in this field. Some studies have evaluated the level of moral reasoning among medical students; however, there are no comparative studies involving other types of populations. Therefore, the objective of this study was to compare the moral reasoning among medical graduates with that of a group of young graduates with other degrees and of a group of nonprofessional adults. METHODS: An exploratory cross-sectional study was conducted. Pediatric residents and pediatric subspecialty residents at a pediatric hospital were invited to participate, forming the group of "medical graduates". A group of young people from a social program and students with a master's degree in a science from the same pediatric hospital were also invited to participate, comprising the group of "graduates with other degrees". Finally, a group of beneficiaries of a family clinic was invited to participate, which we categorized as "nonprofessionals". To evaluate the differences in moral reasoning between these 3 groups, we applied the Defining Issues Test (DIT), a moral reasoning questionnaire designed by James Rest using Kohlberg's theory of moral development. RESULTS: The moral reasoning of 237 subjects-88 from the "medical graduates" group, 82 from the "graduates with other degrees" group and 67 from the "nonprofessionals" group- was evaluated. We found differences in the profiles of moral development of the groups. The profile of the "nonprofessionals" showed a very high predominance of subjects at the preconventional level, 70%, but only 4.5% at the postconventional level. Among the "medical graduates", we observed 37.5% at the preconventional level and 34% at the postconventional level (X2 p < 0.001); this group had the highest percentage in this category. This large difference could be because the differences in the ages and socioeducational levels of nonprofessionals are much wider than those among medical graduates. However, significant differences were also found when the profiles of medical graduates were compared with those of graduates with other degrees, since the latter demonstrated 56% at the preconventional level and 18% at the postconventional level (X2 test, p = 0.02). CONCLUSIONS: Significant differences were found in moral reasoning among the groups that we evaluated. Among the group of medical graduates, there was a higher percentage of subjects at the postconventional level than among the group of graduates with other degrees and a much higher percentage than among the group of nonprofessionals. Our conclusions give the first evidence that studying medicine seems to influence the development of moral reasoning in its students. Therefore, we consider it relevant to develop educational strategies where the student is involved in simulated but realistic decision-making situations, where there are moral dilemmas to resolve from their early years of training.

A pharmaco-economic analysis of second-line treatment with imatinib or sunitinib in patients with advanced gastrointestinal stromal tumours.

Second-line treatments recommended by the National Cancer Center Network to manage advanced-stage gastrointestinal stromal tumours (GIST) were evaluated to determine the cost and cost-effectiveness of each intervention in the Mexican insurance system, the Instituto Mexicano del Seguro Social (IMSS). Treatments examined over a 5-year temporal horizon to estimate long-term costs included 800 mg day(-1) of imatinib mesylate, 50 mg day(-1) of sunitinib malate (administered in a 4 week on/2 week rest schedule), and palliative care. The mean cost (MC), cost-effectiveness, and benefit of each intervention were compared to determine the best GIST treatment from the institutional perspective of the IMSS. As sunitinib was not reimbursed at the time of the study, a Markov model and sensitivity analysis were conducted to predict the MC and likelihood of reimbursement. Patients taking 800 mg day(-1) of imatinib had the highest MC (+/-s.d.) of treatment at $35,225.61 USD (+/-1253.65 USD); while sunitinib incurred a median MC of $17,805.87 USD (+/-694.83 USD); and palliative care had the least MC over treatment duration as the cost was $2071.86 USD (+/-472.88 USD). In comparison to palliative care, sunitinib is cost-effective for 38.9% of patients; however, sunitinib delivered the greatest survival benefit as 5.64 progression-free months (PFM) and 1.4 life-years gained (LYG) were obtained in the economic model. Conversely, patients on imatinib and palliative care saw a lower PFM of 5.28 months and 2.58 months and also fewer LYG (only 1.31 and 1.08 years, respectively). Therefore, economic modeling predicts that reimbursing sunitinib over high dose imatinib in the second-line GIST indication would deliver cost savings to the IMSS and greater survival benefits to patients.

Infection of pregnant women with hepatitis B and C viruses and risks for vertical transmission.

Pregnant women infected with hepatitis B and C viruses pose a risk for infecting their newborn infants by vertical transmission. We studied 6,253 pregnant women aged 12-49 years for infection with hepatitis B (HBV) and C (HCV) viruses. Infection was diagnosed by measuring IgG antibodies against HBc, HBs, HBe, as well as IgM-HBc and HCV viral antigens with commercially available immunoassay kits. HBV infection was detected in 113 cases (1.8%), and prevalence was significantly higher (2.4%) in a group of women with a high-risk pregnancy who were attending a perinatology hospital than in healthy pregnant women (1.67%, p < 0.05). Infection with HBV was significantly higher in women older than 30 years old (p < 0.05). HBsAg was found in blood, colostrum and vaginal exudate of two pregnant women; HBsAg was detected in the gastric aspirate but not in the blood of the two newborn infants. HBeAg and IgM-HBc were not detected in any of the samples. DNA-HBV was detected in serum of seven women, and DNA-HBV was detected in the gastric aspirate of only one of the newborns. HCV infection was diagnosed in three out of 111 women with markers for HBV infection (2.7%), and in 6 out of 1,000 women without these markers (0.6%). Anti-HCV antibodies were found in the serum of six of their infants during up to six months of age. Infants were monitored for one year and none of them developed any sign of hepatic disease. These results suggest that special attention should be paid to women older than 30 years and with a high-risk pregnancy, as they are at a higher risk of HBV and HCV infections.

Preferences of Mexican anesthesiologists for vecuronium, rocuronium, or other neuromuscular blocking agents: a survey.

BACKGROUND: Several neuromuscular blocking (NMB) agents are available for clinical use in anesthesia. The present study was performed in order to identify preferences and behaviors of anesthesiologists for using vecuronium, rocuronium or other NMB agents in their clinical practice. MATERIAL AND METHODS: The cross-sectional survey was applied at the Updated Course of the Colegio Mexicano de Anestesiología performed last year. Of 989, 282 (28.5%) surveys were returned. RESULTS: Most anesthesiologists were working at both public and private hospitals, performed anesthetic procedures for hospitalized and ambulatory patients, and anesthetized children as well as adults. Respondents did not consider mechanomyography as the gold standard method for neuromuscular monitoring. The T25 was not recognized as a pharmacodynamic parameter that represents the clinical duration of the neuromuscular block. Most answered that vecuronium induces less histamine release than rocuronium, had never used any neuromuscular monitor, did not know the cost of vecuronium and rocuronium, and preferred rocuronium in multiple-sampling vials and vecuronium in either a vial for single or multiple sampling. Rocuronium was preferred for emergency surgery in patients with full stomach only. Almost all of anesthesiologists that conserve the unused drug did it without refrigeration and more than 30% conserve the unused drug in one syringe for further use. CONCLUSION: Vecuronium was preferred for most clinical situations, and the decision for this choice was not based on costs. Storage of unused drugs without refrigeration in a single syringe for purpose of future use in several patients represented a dangerous common practice.

[Factors associated with peritoneal dialysis catheter failure in chronic renal insufficiency]. / Factores asociados a falla del catéter de diálisis peritoneal en insuficiencia renal crónica.

AIM: To determine the frequency, time of occurrence and factors associated with the failure of the permanent peritoneal catheter during dialysis in cases of chronic renal failure (CRF). MATERIAL AND METHODS: A retrospective cohort under a nested case control design was studied at a second level health care unit of the Instituto Mexicano del Seguro Social. A total of 149 catheters, double cushion straight Tenckhoff type, were evaluated in 74 patients with CRF due to diabetic nephropathy in 36/74 patients (49%). Information concerning functionality time and causes of catheter failure as well as the clinical and technical factors concerning insertion were obtained from the clinical chart. RESULTS: The cumulated time of dialysis was 814 months. Catheter failure occurred in 101 cases (68%): 67 due to obstruction, 24 due to infection, to leakage in 6 and to other causes in 4. Those of non-infectious origin were more frequent (p < 0.01). In the first month post-insertion there was a higher number of failures than after one month, (p < 0.0005). The global functionality of the catheter at one month, one and two years was 55%, 31% and 16%, respectively. There was a greater permanence of the catheters in continuous ambulatory peritoneal dialysis than in intermittent peritoneal dialysis (p = 0.02). CONCLUSIONS: It is concluded that the frequency of the peritoneal catheter failure was high; that the most frequent cause was due to non-infectious complications during the first month of insertion; and the factor associated to catheter failure was intermittent peritoneal dialysis as compared to continuous ambulatory dialysis.

[Frequency of depression in patients with diabetes mellitus type 2]. / Frecuencia de depresión en pacientes con diabetes mellitus tipo 2.

OBJECTIVE: To determine the prevalence of depression in Mexican adult diabetics and to identify factors associated to the depression. RESEARCH DESIGN: Prolective survey. SETTING: Four Mexico City hospitals (Clinica San Pedro de los Pinos IMSS, Centro Medico Nacional Siglo XXI IMSS, Hospital Gea González SSa and Centro de Salud Margarita Chorne SSa). STUDY UNITS: 79 patients with diabetes mellitus type 2. MAIN MEASUREMENTS: The Beck Depression Inventory was used as a measure of depression. We used sociodemographic variables (age, gender, marital status, religion, education, occupation, socioeconomic status) and disease variables (years of diagnosis, other chronic medical conditions and compliance with therapeutic regimens) as the independent variables of depression. RESULTS: Mean age was 59 +/- 11 years (SD) and 58 (73%) were females. The frequency of depression was 46%. Factors associated to depression were: females (OR = 3.67, CI = 1.07-13.3, p = 0.03) and years of diagnosis above 15 (OR = 3.08, CI = 0.91-10.8, p = 0.07). CONCLUSIONS: Frequency of depression was high (46%). Gender and years of diabetes diagnosis were factors associated to depression.

[Frequency and risk factors associated with metronidazole therapeutic noncompliance]. / Frecuencia y factores de riesgo asociados al incumplimiento terapéutico con metronidazol.

OBJECTIVE: to determine the frequency and risk factors of non-compliance to oral metronidazole. STUDY DESIGN: comparative cross-sectional survey. STUDY UNITS: 111 patients who received oral metronidazole. SETTING CHARACTERISTICS: two medical units: one primary level unit and one secondary care unit of the Mexican Institute of Social Security. MEASUREMENTS: non-compliance was assessed by home interview and pill count. MAIN RESULTS: frequency of non-compliance was 55%. Risk factors for non-compliance were: female sex (OR = 3.0; p less than 0.05); side effects (OR = 3.1; p less than 0.05); low literacy (OR = 3.75; p less than 0.05). Stratified analysis showed no interaction between variables. CONCLUSIONS: frequency of non-compliance to metronidazole is high, and could affect the effectiveness of medical care. Female patients with low literacy and who suffer side effects are a high risk group for non-compliance.

[Diagnostic performance of immunologic tests in amebic liver abscess using receiver operating characteristic curves]. / Rendimiento diagnóstico de las pruebas inmunológicas en absceso hepático amibiano a través de curvas de características operantes del receptor.

Objectives. 1) To identify the tests of immunological diagnosis with a high diagnostic efficiency in amebic liver abscess. 2) To determine the ideal cutoff point for such tests. 3) To identify the influence degree of the antigen used over the test efficiency. Design. Comparative survey. Study units. Analysis of 24 articles identified in the medical literature about tests of immunological diagnosis in amebic liver abscess. Measurements. Starting from the articles, operating characteristics curves (ROC) were established derived from the test application to patients with amebic liver abscess. Results. A great variability in the diagnostic efficiency was identified between the various tests, even when the analysis was focused on the investigations of a specific test. It was not possible to conclude which test had a major degree of efficiency due to such variability. The cutoff level considered as relevant was higher than the one traditionally used for indirect hemagglutination and it had concordance with the one presently accepted for the fluorescence antibodies test. By maintaining steady the spectrum of the study patients and the type of test, variability among the tests persisted. This was due to the use of different antigens. Conclusions. A great variation in the diagnostic efficiency of the analyzed tests was identified. The variation source was the type of test, the antigen used and probably the illness spectrum.

Validation of a prognostic index in the critically ill newborn.

OBJECTIVE: Elaborate and assess the degree of validity of a prognostic model for evaluating patients admitted to the Neonatal Intensive Care Unit (NICU). DESIGN: Cases and controls nested in a cohort. SETTING: NICU of two tertiary hospitals and another second level hospital. PATIENTS: The study was carried out in two phases. During the first phase (elaboration of a model), 336 newborns were studied; 112 belonged to the case group (dead patients) and 224 to the control group (live patients discharged). For the second phase (model validation), 300 patients were included that did not participate in the first phase, 100 cases and 200 controls. MEASUREMENTS: For each patient admitted to the study, clinical, paraclinical, perinatal and comorbidity factors were determined within the first 12 hours. Variables of statistical significance in the bivariate analysis were included in a logistic regression model with the objective of identifying a prognostic model. RESULTS: The variables that constituted the prognostic index were gestational age x birth weight, the paO2/FiO2 ratio x O2 saturation, arrest cardiac, major congenital malformations, septicemia and base excess. The model showed to have a sensitivity of 70% and a specificity of 91% during the elaboration cohort. In the validation cohort, sensitivity was 68% and specificity was 92%, a positive predictive value of 80%, negative predictive value of 85% and a correct classification rate was 84%. CONCLUSIONS: The Neonatal Mortality Prognostic Index (NMPI) developed in this study showed to be useful for the evaluation of hospital mortality for severely ill newborns admitted to NICU.

[Classification by levels of clinico-epidemiological research designs]. / Clasificación en niveles de los diseños de investigación clínico-epidemiológicos.

The objective was to identify the characteristics of epidemiologic designs enabling their classification. A critical review of the literature in the clinical epidemiologic area was done to establish the main differences between designs. A meeting with experts to discuss this controversial topic and obtain criteria by consensus was organized. We propose an integral classification based on levels with two fundamental shafts: intervention and explanatory reasoning.

Satisfaction related factors of attendants to a medical research meeting.

OBJECTIVE: To assess satisfaction of attendants to a National Meeting on Medical Research in relation with the scientific quality and level of discussion of the research work. MATERIAL AND METHODS: An anonymous self-applied questionnaire was handed out to gather opinions about the scientific quality, level of discussion of the research work, and overall satisfaction with the meeting. The studied population included 400 physicians, all of them authors or collaborators of the research work presented. RESULTS: The rate of response was 62% (n = 249). Two hundred and twenty-four approved the scientific quality (90%), and 203 were satisfied with the level of discussion of research (88%); 239 were satisfied with the meeting as a whole (96%). The factors associated with dissatisfaction regarding the quality of the scientific meeting were the masculine gender (OR = 2.7, CI 95% = 0.8-9.l, p = 0.06), having an M.Sc. or Ph.D. degree (OR = 2.3, CI 95% = 0.9-5.5, p = 0.03), and having attending prior meetings more than twice (OR = 5.0, CI 95% = 1.5-18.4, p = 0.001). CONCLUSIONS: Most of the attendants were satisfied with the scientific quality and discussions of the research work. The masculine gender, having an M.Sc. or Ph.D. degree, and prior assistance were the factors associated with dissatisfaction of the scientific quality of the Meeting.

[Medical student traits associated with future success as physicians]. / Características del estudiante de medicina asociadas al éxito ulterior como médico.

OBJECTIVE: To identify the individual and family factors present during medical studies which are associated to success as a physician. RESEARCH DESIGN: Prolective case-control study. SETTING: Mexico City metropolitan area. STUDY UNITS: 120 physicians considered to be successful and 245 physicians who according to an established criteria were considered to be non-successful. MAIN MEASUREMENTS: A success-achieving index was constructed on the opinion of 134 physicians from different health-care institutions private and public. The index was composed by criteria such as being a member of prestiged academic associations; having a practice in third level institutions; having done postgraduate studies; being a professor with teaching and research activities; having obtained directive medical positions; and a high income at the moment of the interview. RESULTS: The main factors associated to success were: frequent attendance to cultural activities by the family of the subjects (OR = 5.2, IC 95% = 3.15-8.60, p = 0.00000001); the global score obtained during their medical studies, i.e. higher than 8.5 over 10 (OR = 4.43, IC 95% = 2.64-7.49, p = 0.00000001); and having been awarded recognitions, prizes or scholarships during their medical studies (OR = 4.3, IC 95% = 2.64-7.03, p = 0.00000001). A logistic regression model selected the cultural activities of the family, global score during medical studies and earning of recognitions, prizes and scholarships as independent variables associated to success achievement (p = 0.00001). CONCLUSIONS: Frequent cultural activities by the family and academic behavior were the factors present during medical studies which were associated to ulterior success as a physician.

[Diagnostic tests for amniotic infection: review of the literature]. / Pruebas diagnósticas de infección amniótica: revisión de la literatura.

The diagnosis of intraamniotic infection (IAI) is not difficult when clinical manifestations are present, but there are patients with subclinical infections, in these cases the examination of the amniotic fluid is the most important diagnostic procedure. We made a critical review of the medical literature of diagnostic tests of IAI, according to the analysis criterion of the medical articles of the Department of Clinical Epidemiology of the McMaster University. The articles were identified looking for in the MEDLINE-CD ROOM and INDEX MEDICUS from 1991 to 1995. We identified 19 articles, none of them complied with all of the analysis criterion, none of the studies were blinded nor independently compared with a gold standard test and only five articles studied a full spectrum of patients. The articles with better methodologic design were those that studied the interleukin-6 role as diagnostic test for IAI; they showed a sensibility between 75 to 89% and a specificity of 97 to 100%; nevertheless it is still necessary to standardize the cut-off point of the interleukin-6 levels.

[A fibrolamellar variety of hepatocarcinoma in a young woman 17 years old]. / Hepatocarcinoma variedad fibrolamelar en una joven de 17 años de edad.

We report here the case of a 17-year-old female with typical fibrolamellar hepatocellular carcinoma, no hepatitis B or C viral infection and a normal, non-cirrhotic liver. Computed tomography and magnetic resonance imaging revealed a solid tumor with a central fibrous scar. A fibrolamellar hepatocellular carcinoma is an uncommon malignancy of unknown etiology, without cirrhosis, usually without an increase in tumor markers, and rarely associated with hepatitis B virus. It occurs mainly in young patients. This tumor presents a high resectability rate (48-100%), a good prognosis and a mean survival of 68 months. This tumor is an important differential diagnosis of space occupying lesions in younger adults.

[Bibliometric analysis of publications by the Mexican Social Security Institute staff]. / Análisis bibliométrico de las publicaciones realizadas por el personal del IMSS.

OBJECTIVE: To describe and analyze the general characteristics and methodology of indexed publications by the health staff of the Mexican Social Security Institute in 1997. MATERIAL AND METHODS: Original articles were evaluated. The primary sources included Index Medicus, Current Contents and the Mexican National Council of Science and Technology (CONACYT) index. The following information was gathered for each article: affiliation and chief activity of the first author; impact factor of the journal; research type; field of study; topic of study, and methodological conduction. This latter point included congruence between design and objective, reproducibility of methods, applicability of the analysis, and pertinence of the conclusions. RESULTS: A total of 300 original articles was published of which 212 (71%) were available for the present study: full-time investigators (FTI) generated 109 articles and investigators with clinical activities (CAI) wrote 103 articles. The median impact factor of the journals in which FTI published was 1.337 (0.341 to 37.297) and for CAI publications, 0.707 (0.400 to 4.237). Biomedical research predominated in the first group (41%) and clinical investigation in the second (66%). Statistically significant differences were identified for the methodological conduction between groups of investigators. CONCLUSIONS: Descriptive studies and publications in journals without impact factor predominated. The FTI group had the highest bibliographic production of original articles in indexed journals with an impact factor.

[Observer variation in diagnostic procedures related to cardiothoracic surgery]. / Variabilidad de observador en procedimientos diagnósticos afines a la cirugía cardiotorácica.

The results reliability is a predominant condition in the validity of clinical research. The observer agreement determination is a useful procedure in the confirmation of the obtained results in clinical research. The present work is a presentation of the basis about observer agreement and a review of national publications in cardiology, pneumology and cardiothoracic surgery between january 1980 and july 1993, where we found just two publications with the application of observer agreement determination in echocardiography, electrocardiography, microscopy and hemodynamics. It was concluded that is necessary the increase in determination of observer agreement and inform this results in our publications, excluding the variability attributed to patients, diagnostics equipment or the circumstances.