RESUMEN

BACKGROUND: Acute gastroenteritis (AGE) burden, etiology, and severity in adults is not well characterized. We implemented a multisite AGE surveillance platform in 4 Veterans Affairs Medical Centers (Atlanta, Georgia; Bronx, New York; Houston, Texas; and Los Angeles, California), collectively serving >320 000 patients annually. METHODS: From 1 July 2016 to 30 June 2018, we actively identified inpatient AGE case patients and non-AGE inpatient controls through prospective screening of admitted patients and passively identified outpatients with AGE through stool samples submitted for clinical diagnostics. We abstracted medical charts and tested stool samples for 22 pathogens by means of multiplex gastrointestinal polymerase chain reaction panel followed by genotyping of norovirus- and rotavirus-positive samples. We determined pathogen-specific prevalence, incidence, and modified Vesikari severity scores. RESULTS: We enrolled 724 inpatients with AGE, 394 non-AGE inpatient controls, and 506 outpatients with AGE. Clostridioides difficile and norovirus were most frequently detected among inpatients (for AGE case patients vs controls: C. difficile, 18.8% vs 8.4%; norovirus, 5.1% vs 1.5%; P < .01 for both) and outpatients (norovirus, 10.7%; C. difficile, 10.5%). The incidence per 100 000 population was highest among outpatients (AGE, 2715; C. difficile, 285; norovirus, 291) and inpatients ≥65 years old (AGE, 459; C. difficile, 91; norovirus, 26). Clinical severity scores were highest for inpatient norovirus, rotavirus, and Shigella/enteroinvasive Escherichia coli cases. Overall, 12% of inpatients with AGE had intensive care unit stays, and 2% died; 3 deaths were associated with C. difficile and 1 with norovirus. C. difficile and norovirus were detected year-round with a fall/winter predominance. CONCLUSIONS: C. difficile and norovirus were leading AGE pathogens in outpatient and hospitalized US veterans, resulting in severe disease. Clinicians should remain vigilant for bacterial and viral causes of AGE year-round.

Asunto(s)

RESUMEN

BACKGROUND: Norovirus is an important cause of epidemic acute gastroenteritis (AGE), yet the burden of endemic disease in adults has not been well documented. We estimated the prevalence and incidence of outpatient and community-acquired inpatient norovirus AGE at 4 Veterans Affairs Medical Centers (VAMC) (Atlanta, Georgia; Bronx, New York; Houston, Texas; and Los Angeles, California) and examined trends over 4 surveillance years. METHODS: From November 2011 to September 2015, stool specimens collected within 7 days of AGE symptom onset for clinician-requested diagnostic testing were tested for norovirus, and positive samples were genotyped. Incidence was calculated by multiplying norovirus prevalence among tested specimens by AGE-coded outpatient encounters and inpatient discharges, and dividing by the number of unique patients served. RESULTS: Of 1603 stool specimens, 6% tested were positive for norovirus; GII.4 viruses (GII.4 New Orleans [17%] and GII.4 Sydney [47%]) were the most common genotypes. Overall prevalence and outpatient and inpatient community-acquired incidence followed a seasonal pattern, with higher median rates during November-April (9.2%, 376/100 000, and 45/100 000, respectively) compared to May-October (3.0%, 131/100 000, and 13/100 000, respectively). An alternate-year pattern was also detected, with highest peak prevalence and outpatient and inpatient community-acquired norovirus incidence rates in the first and third years of surveillance (14%-25%, 349-613/100 000, and 43-46/100 000, respectively). CONCLUSIONS: This multiyear analysis of laboratory-confirmed AGE surveillance from 4 VAMCs demonstrates dynamic intra- and interannual variability in prevalence and incidence of outpatient and inpatient community-acquired norovirus in US Veterans, highlighting the burden of norovirus disease in this adult population.

Asunto(s)

RESUMEN

The Preparadxs app was designed to enhace the prevention of the HIV and other sexually transmitted infections transmission through the empowerment of the user. The purpose of this study is to determine the usability and perception about the app among real users. In this prospective cross-sectional study all app end-users were asked to answer the System Usability Scale and question regarding app capability to reduce sexually transmitted infections in the future. Influence of several variables (gender identity, educational level and digital native condition) was explored. A total of 69 users answered the survey during study period. Most of them were male and had university studies. Final usability score was 80,8 points which means a good, near excellent usability. No differences in usability scores were observed regarding to gender identity, native condition or educational level. Most users were strongly agree (56,5%) or agree (28,9%) with app potential to reduce the incidence of HIV and other STIs in the future.

Asunto(s)

RESUMEN

BACKGROUND: Norovirus is a leading cause of acute gastroenteritis (AGE); however, few data exist on endemic norovirus disease burden among adults. Candidate norovirus vaccines are currently in development for all ages, and robust estimates of norovirus incidence among adults are needed to provide baseline data. METHODS: We conducted active surveillance for AGE among inpatients at a Veterans Affairs (VA) hospital in Houston, Texas. Patients with AGE (≥3 loose stools, ≥2 vomiting episodes, or ≥1 episode of both loose stool and vomiting, within 24 hours) within 10 days of enrollment and non-AGE control patients were enrolled. Demographic data and clinical characteristics were collected. Stool samples were tested using the FilmArray gastrointestinal panel; virus-positives were confirmed by real-time reverse transcription polymerase chain reaction and genotyped by sequencing. RESULTS: From November 2, 2015 through November 30, 2016, 147 case patients and 19 control patients were enrolled and provided a stool specimen. Among case patients, 139 (95%) were male and 70 (48%) were aged ≥65 years. Norovirus was the leading viral pathogen detected (in 16 of 20 virus-positive case patients) and accounted for 11% of all AGE cases. No viral pathogens were detected among control patients. Incidence of norovirus-associated hospitalization was 20.3 cases/100 000 person-years and was similar among those aged <65 and ≥65 years. CONCLUSIONS: This active surveillance platform employed screening and enrollment of hospitalized VA patients meeting a standardized AGE case definition, as well as non-AGE control patients. Data from this study highlight the burden of norovirus in a VA inpatient population and will be useful in policy considerations of a norovirus vaccine.

RESUMEN

Background Care transitions are risk points for medication discrepancies, especially in the elderly. Objective This study was undertaken to assess prevalence and describe medication reconciliation errors during admission in elderly patients and to analyze associated risk factors. We also evaluate the effect of these errors on the length of hospital stay. Setting General surgery, orthopedics, internal medicines and infectious diseases departments of a 1070-bed Spanish teaching hospital. Method This is a prospective observational study. Patients >65 years and taking ≥5 medications were randomly selected from those admitted to hospital. The pharmacist obtained the best possible medication history based on medical records, medical notes from patients' previous admissions to hospital, "brown bag" review, community care prescriptions, and comprehensive patient interviews. It was compared to current inpatient prescription to detect unintentional discrepancies (discrepancy with no apparent clinical explanation), which were reported to the physician. When the physician accepted the discrepancy by changing the medication order, it was recorded as a medication reconciliation error and classified by type of error. Several variables were analyzed as possible risk/protective factors. Main outcome measure Is prevalence of medication reconciliation errors at admission. Results Reconciliation was performed on 206 patients. Medication reconciliation errors occurred in 49.5 % (102/206) of patients. 1996 medications were recorded, and 359 had unintentional discrepancies (56.0 % (201/359) medication reconciliation errors). The most common was omission (65.1 %). Identified risk factors were as follows: physician experience, number of pre-admission prescribed medications, and previous surgeries. Computerized order entry system was a protective factor. Conclusion Medication reconciliation errors occur in almost half of the elderly patients at admission, especially omissions. Risk factors were a larger number of previous medications, less physician years of experience, and more previous surgeries. Having a computerized order entry system in the hospital protected against some errors.

Asunto(s)

RESUMEN

The evaluation of response to treatment is a critical step for determining the effectiveness of oncology drugs. Targeted therapies such as tyrosine kinase inhibitors and mammalian target of rapamycin inhibitors are active drugs in patients with metastatic renal cell carcinoma (mRCC). However, treatment with this type of drugs may not result in significant reductions in tumor size, so standard evaluation criteria based on tumor size, such as Response Evaluation Criteria in Solid Tumors (RECIST), may be inappropriate for evaluating response to treatment in patients with mRCC. In fact, targeted therapies apparently yield low response rates that do not reflect increased disease control they may cause and, consequently, the benefit in terms of time to progression. To improve the clinical and radiological evaluation of response to treatment in patients with mRCC treated with targeted drugs, a group of 32 experts in this field have reviewed different aspects related to this issue and have put together a series of recommendations with the intention of providing guidance to clinicians on this matter.

Asunto(s)

RESUMEN

Introduction Recent studies have shown an increase in psychiatric symptomatology in medical students and physicians during their professional practice. Some studies show that these professionals have a higher prevalence of psychiatric symptoms than the general population. This phenomenon is a consequence of the particular conditions of this professional activity, and, in the case of students, of high academic demands that lead to stressful situations that interfere with their academic performance and the development of clinical skills, which may have repercussions on their relationship with their patients. The predominant symptoms are anxiety, depression and stress, as well as substance use; there has also been an increase in the number of students with suicide attempts. Most of these problems occur during the first two years of the degree course as well as the internship year. Depression is masked by anger, by virtue of the fact that it is an internalized form of anger. It has also been documented that there is a significant link between certain personality traits and the presence or absence of mental symptoms, regardless of the situations to which people are exposed. The feature with the highest association with the presence of symptomatology is neuroticism, while the personality traits that are most conducive to the achievement of academic success and better adaptation and, therefore, a lower number of symptoms are empathy and kindness. The purpose of this study was to establish a diagnosis of the mental health and personality traits of medical students in the high performance groups and compare them with those of the groups of students that performed poorly during the first two years of the degree course. This transversal, exploratory study involved the participation of 370 students from the UNAM Medical School: 220 belonged to the high performance groups, called educational quality nuclei (NUCE), while 1 50 were repeat students. The variables considered were: age, sex, type of group (NUCE or repeat), academic year (first or second year of the degree), place of origin and type of high school from which they had graduated (public or private). Two instruments were used to measure personality traits and psychiatric symptomatology: the Big Five Personality Traits and the Symptom Check List-90. The results of the study show that in both groups (repeat students and NUCE) over 85% were from the Federal District. Repeat students were mainly women (85.3%) and students from public schools (93.6%). As for the high performance group (NUCE), 83.1 % were from private schools and just 1 6.9% from public schools. Repeat students showed personality traits that included neuroticism and very little openness compared with the high performance groups, which displayed traits of greater openness and less neuroticism, with p<0.01. In general, students from NUCE groups showed traits of greater extraversion, empathy and diligence compared with repeaters. Psychiatric symptomatology was more severe among the repeat group than the NUCE group (p<0.05). The psychiatric symptomatology displayed by both groups included: obsession-compulsion, depression and anxiety. In the comparisons, the two groups showed significant differences in total symptomatology. There were also differences in the following symptomatology, by order of importance: phobia, interpersonal sensitivity, somatization, anxiety, obsessive-compulsive disorder and psychoticism (p<0.05). Differences were found between academic years, with second-year students showing greater symptomatology; women displayed the greatest symptomatology. No differences were found for the interaction between sex and academic year. The analysis of structural models was used to determine the relationship between the variables being studied, with significant correlation coefficients with p<.05 being found between personality and sex, personality and type of high school, as well as type of group and suicidal ideation, academic year and psychiatric symptomatology, personality and suicidal ideation and personality and psychiatric symptomatology. The results of the study coincided with those in the literature, although there were some differences between the two groups of students. Repeat students displayed greater levels of psychiatric symptomatology compared with students in the high performance groups. This suggests that students who perform less well in their degree courses also report higher mean responses in psychiatric symptomatology, mainly on scales of somatization, anxiety, phobia and interpersonal sensitivity. As for type of personality, students in the high performance group reported higher average scores on the scales of extraversion, empathy and openness, with the exception of the neuroticism scale. This suggests that personality features may be predictors of better academic performance as well as greater intellectual skill. This finding is reinforced by the repeater group's results, since they report higher scores in the personality trait of neuroticism. The diligence scale was the same for both groups. The study corroborated the fact that second-year students display the greatest symptomatology, with women reporting higher averages in psychiatric symptomatology scores (mean = 7.3). Sex is associated with greater empathy and solidarity, with women achieving higher scores in both personality traits. Although the neuroticism trait is also associated with the female sex and suicidal ideation, scores for this trait were higher for men. This trait can be considered a predictor for both suicidal ideation and the presence of a higher number of psychiatric symptoms. Lastly, the symptomatology in which these students obtained the highest scores is related to the obsessive-compulsive disorder, a situation which we consider may be due to the type of screening test used. It is a fact that studying medicine involves continuously stressful conditions. For these students, however, seeking help to cope with the presence of psychiatric symptomatology is extremely complicated since they regard it as a form of weakness. This raises the need to develop large-scale programs to orient students in order to enable them to identify symptoms at an early stage, which in turn will permit timely treatment.

En estudios recientes se ha demostrado un incremento en la sintomatología psiquiátrica que presentan los estudiantes de medicina, así como los médicos durante su ejercicio profesional. En algunos estudios se señala que estos profesionistas tienen una prevalencia de síntomas psiquiátricos por arriba de los de la población general. Este fenómeno es una consecuencia de las condiciones propias de la actividad profesional y, en el caso de los alumnos, por situaciones que demandan una mayor exigencia académica, que conlleva a su vez situaciones estresantes que interfieren en su desempeño académico, así como en el desarrollo de habilidades clínicas que pueden repercutir en su relación con los pacientes. Los síntomas que predominan son la ansiedad, la depresión y el estrés, así como el consumo de sustancias; también se ha incrementado el número de estudiantes con intentos de suicidio. Se observa que la mayoría de estos problemas tipo se presentan en los dos primeros años de la carrera, así como en el año de internado. La depresión se encuentra enmascarada por enojo, en virtud de que ésta representa un enojo internalizado. Asimismo se ha documentado que existe una relación importante entre la presencia de ciertos rasgos de personalidad y la presencia o ausencia de síntomas mentales, independientemente de las situaciones a las que se expongan las personas. El rasgo que presenta una mayor asociación con la presencia de sintomatología es el neuroticismo, así como también los rasgos de personalidad que influyen con un mejor cumplimiento de logros académicos y una mejor adaptación. El objetivo de este trabajo fue establecer un diagnóstico de la salud mental y los rasgos de personalidad de los estudiantes de medicina que se encuentran en los grupos de alto rendimiento y compararlo con los grupos de alumnos que presentan bajo rendimiento académico durante los dos primeros años de la carrera. En este estudio exploratorio, de tipo transversal, participaron 370 estudiantes de la Facultad de Medicina de la UNAM: 220 correspondían a los grupos de alto rendimiento, llamados núcleos de calidad educativa (NUCE), y 150 eran alumnos repetidores. De entre los resultados que arrojó el estudio, se encontró que para ambos grupos (repetidores y NUCE) más de 85% provenía del Distrito Federal. En el grupo de repetidores predominaron las mujeres (85.3%) y los alumnos procedentes de escuelas públicas (93.6%). En relación con el grupo de alto rendimiento (NUCE), 83.1% procedía de escuelas privadas y sólo 16.9% de escuelas públicas. Los alumnos repetidores mostraron rasgos de personalidad de neuroticismo y de poca apertura en comparación con los grupos de alto rendimiento, quienes mostraron rasgos de mayor apertura y menor neuroticismo, con una p<0.01. En general, los alumnos de los grupos NUCE mostraron rasgos de mayor extroversión, mayor empatía y diligencia en comparación con los repetidores. La sintomatología psiquiátrica mostró mayor gravedad en el grupo repetidor con respecto al grupo NUCE (p<0.05). La sintomatología psiquiátrica que presentaron ambos grupos fue: obsesión-compulsión, depresión y ansiedad. Entre las comparaciones resultaron diferencias significativas en ambos grupos en el total de sintomatologías. También hubo diferencias en las siguientes sintomatologías por orden de importancia: fobia, sensibilidad interpersonal, somatización, ansiedad, trastorno obsesivo-compulsivo y psicoticismo (p<0.05). Los resultados del estudio presentan coincidencias con lo publicado por la bibliografía; sin embargo, hay diferencias entre ambos grupos de estudiantes. En los alumnos repetidores se observó mayor sintomatología psiquiátrica en comparación con los alumnos de los grupos de alto rendimiento. Por lo anterior, se concluye que los alumnos que presentan menores niveles de logro en la carrera también presentan medias de respuestas mayores en sintomatología psiquiátrica, principalmente en las escalas de somatización, ansiedad, fobia y sensibilidad interpersonal.

RESUMEN

Objetivo: Determinar la utilidad de las distintas pruebas radiológicas (esofagograma, radiología convencional y tomografía computarizada [TC] de tórax), en el diagnóstico de la perforación esofágica no iatrogénica. Material y métodos: Estudio retrospectivo de las perforaciones esofágicas no iatrogénicas diagnosticadas en nuestro servicio, con revisión de las pruebas radiológicas llevadas a cabo. Se recogieron cinco casos (cuatro con síndrome de Boerhaave y uno con efracción esofágica por desaceleración). En todos, la localización de la perforación fue el esófago distal. Se realizó radiología convencional de tórax a cuatro pacientes, consecutivamente TC y esofagograma a dos, a otros dos sólo TC y a uno únicamente esofagograma. El diagnóstico se confirmó mediante TC (dos casos), esofagograma (un caso), cirugía (un caso) y tanto con TC como con esofagograma (un caso).Resultados: El neumomediastino fue el signo más frecuentemente hallado en radiología convencional. Se obtuvo un resultado falso negativo en el esofagograma. Todos las TC mostraron la presencia de aire extraluminal, con localización más frecuente en mediastino. Se evidenciaron dos derrames pleurales de localización izquierda y la presencia de detritus en situación paraesofágica distal (mediastinitis incipiente) en dos ocasiones. Se obtuvo la visión directa de la perforación en dos casos. En dos pacientes (40 por ciento), la perforación no se sospechó, y fue la TC la que dio la clave para el diagnóstico. Conclusiones: La radiología convencional muestra signos inespecíficos que es necesario confirmar mediante otros procedimientos diagnósticos. La TC es un método útil, sobre todo en casos de presentación atípica, en los falsos negativos del esofagograma y para valorar la extensión mediastínica del proceso. En la TC, el signo más frecuente y de mayor utilidad es la presencia de aire extraluminal (AU)

Asunto(s)