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Introducción: Las decisiones humanas son parcialmente racionales. En medicina, los escenarios críticos dificultan la toma de decisiones (TD). En esta revisión, proponemos el enfoque "4E" para mejorar la TD de intervenciones. Las "4E" incluyen decisiones: "eficaces" cuando las intervenciones han sido probadas en entornos controlados, "efectivas" cuando las intervenciones han sido probadas en entornos clínicos no controlados o pragmáticos, "eficientes" cuando los beneficios de una nueva intervención se evalúan con relación a sus costos, y decisiones que promuevan "equidad" cuando estas intervenciones se recomiendan de acuerdo con las necesidades del paciente, evitando barreras. El uso de este enfoque podría mejorar la TD en la práctica clínica, pero no es suficiente para garantizar su incorporación y uso. También es importante promover una dinámica organizativa, institucional y política de los sistemas de salud que promuevan el uso crítico de la evidencia para tomar decisiones.

Background:Human decisions are partially rational. In medicine, critical scenarios make decide-making (DM) difficult. In this review, we propose the "4E" approach to improve the DM of interventions. The "4E" approach includes decisions: "effectual" when interventions have been tested in controlled settings, "effective" when interventions have been tested in uncontrolled or pragmatic clinical settings, "efficient" when the benefits of a new intervention are evaluated by its costs, and decisionsthatpromote"equity"whentheseinterventionsare recommended according to the needs of the patient, avoiding barriers. Using this approach could improve DM in clinical practice, but it is not enough to guarantee its incorporation and use. It is also essential to promote the organizational, institutional, and political dynamics of health systems that promote evidence's critical use to make decisions

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BACKGROUND: Stroke represents one of the major causes of death and long-term disability worldwide and, even when new treatment strategies have been identified, there is a need of quality clinical practice guidelines (CPGs) to guide and improve acute stroke care. We aim to describe the characteristics and assess the quality of CPGs in endovascular treatment for acute ischemic stroke due to anterior-circulation large-vessel occlusion. METHODS: We conducted a scoping review of CPGs that assessed stroke management. We searched the following databases: PubMed, TripDatabase, Scopus, and Google Scholar to identify CPGs published or updated in the last 3 years and used Appraisal of Guidelines Research and Evaluation II to assess the quality of the guidelines. RESULTS: We found a total of 9 CPGs published or updated between 2018 and 2020, from which only one third had adequate methodologic rigor. Guidelines presented pitfalls related to evidence search, assessment, and methods used to reach the recommendations. All the CPGs considered a 24-hour extended window of treatment and the CPGs considered the use of similar imaging techniques to diagnose and explore the extent of the stroke. However, there were variations regarding the selection criteria for thrombectomy. CONCLUSIONS: The quality of the CPGs varied widely, which issues around the identification and assessment of the evidence used to reach recommendations. Despite this, the recommendations regarding the use of thrombectomy were similar across the CPGs. Readers need to carefully assess the methodologic rigor of CPGs before applying them to their clinical practice.

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OBJECTIVE: to evaluate the capacity of Imipenem as a prophylactic treatment for decreasing the number of infected necrosis and surgeries, as well as for diminishing septic complications and the mortality rate among patients with severe acute necrotizing pancreatitis. MATERIAL AND METHODS: from May 2005 to December 2007 a prospective randomized study was conducted in order to evaluate the efficacy of a prophylactic antibiotic therapy in patients with pancreatic necrosis. During this time period 58 patients entered the study protocol. Patients were divided in two groups; the first one underwent antibiotic therapy with Imipenem while the second group received no prophylactic treatment at all. All patients received early enteral nutrition. RESULTS: both studied groups had comparable age, gender ratio, and C.R.P and necrosis percentages. When comparing general morbidity in both groups no difference was found between the group receiving a prophylactic antibiotic and the group that did not receive it (58% vs. 56%). Moreover, when the septic complications were evaluated, it was confirmed that these were more frequent among the group of patients receiving Imipenem (29%), in comparison to the group that did not received antibiotics (15%). 12.5% of the patients that received Imipenem developed pancreatic necrosis infection, while said infection only appeared in 6% of the patients in the group that did not receive antibiotic prophylaxis; nevertheless, none of the comparisons reached statistical significance. The number of patients who required surgery was similar in both groups. When comparing the hospital stay, it was observed that this was longer among the patients receiving prophylactic therapy. No patient died during the study. CONCLUSION: The present study finds no benefits in the use of antibiotic therapy with Imipenem regarding the risk of developing pancreatic necrosis infection and septic complications, and neither when trying to reduce the number of surgeries among patients with severe acute pancreatitis with necrosis.

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OBJECTIVE: The purpose of this study is to define the factors that condition complications and mortality in a group of 119 patients with periampullary neoplasms operated on at a general hospital. MATERIALS AND METHOD: Between October 2002 and December 2006, 119 patients who were diagnosed with periampullary neoplasms and underwent a pancreatoduodenectomy at Rebagliati Hospital were evaluated. RESULTS: Age and sex were not conditioning factors of complications. A significant difference in the type of pancreatic anastomosis used was noticed, whereby telescoping was a conditioning factor of complication (p<0.009) compared with mucous-mucous anastomosis.After analyzing the bleeding associated with each complication, a significant connection was established between the greatest bleeding volume obtained in the operating room with the development of pancreatic fistulas (p<0.03), re-operation (p<0.01), abscesses (p<0.006) and intestinal fistulas (p<0.001).The complications related to mortality in patients who underwent a pancreatoduodenectomy (PD) were evaluated. It was observed that pancreatic fistulas (p<0.003), intestinal fistulas (p<0.003) and gallbladder fistulas (p<0.03), intra-abdominal hemorrhaging and bleeding during a standard operating procedure (SOP), transfusions and re-operations were factors that increased mortality significantly. When the surgeon was evaluated as a factor of morbimortality, it was proven that there was a connection between the surgical volume and the incidence of complications and mortality.There was a shorter hospital stay, a lower incidence of intra-operative bleeding and lower morbimortality in the high surgical volume group. CONCLUSIONS: The most-feared complications, since they are directly related to mortality, are intestinal fistulas, intra-abdominal hemorrhaging, intra-abdominal abscesses, gallbladder fistulas and the need to undergo repeated operations. Both complications and mortality are directly related to the surgeon factor, which, according to our analysis is the most important factor in decreasing costs, morbidity and mortality in this type of surgery.

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El propósito de este estudio, es definir cuales son los factores que condicionan las complicaciones y la mortalidad en un grupo de 119 pacientes con neoplasias peri ampulares operados en un hospital general. MATERIAL Y MÉTODO: Desde Octubre del 2002 hasta Diciembre del 2006 se analizaron 119 pacientes operados de duodenopancreatectomía en el hospital Rebagliati por el diagnostico de neoplasia peri ampular.RESULTADOS: La edad y el sexo no fueron factores condicionantes de complicaciones. Se observo una diferencia significativa en el tipo de anastomosis pancreática utilizadadonde el telescopaje fue un factor condicionante de complicación (p<0.009) Cuando se comparó con a la anastomosis mucosa-mucosa. Al analizar el sangrado con cada una de las complicaciones, se pudo ver que existía una relación significativa entre el mayor volumen de sangrado en sala de operaciones con el desarrollo de fístula pancreática (p<0.03), reoperación (p<0.01), absceso (p<0.006), y fístula intestinal (p<0.001). Se evaluó cuales fueron las complicaciones relacionados a la mortalidad en los pacientes sometidos a Pancreatoduodenectomía (PD), se pudo observar que la fístula pancreática (p<0.003), la fístula intestinal (p<0.003), la fístula biliar (p<0.03), la hemorragia intra abdominal, el sangrado en Sala de Operaciones (SOP), las transfusiones y las reoperaciones fueron factores que aumentaron la mortalidad, en forma significativa. Cuando se evaluó al cirujano como factor de morbi-mortalidad, se pudo comprobar queexistía una relación entre el volumen quirúrgico y la incidencia de complicaciones y mortalidad. Teniendo una menor estancia hospitalaria una menor incidencia en el sangradointra operatorio y una morbi-mortalidad menor en el grupo de alto volumen quirúrgico. CONCLUSIONES: Las complicaciones más temidas ya que se relacionan directamente con la mortalidad son: la fístula intestinal, hemorragia intra abdominal, absceso intraabdominal, fístula biliar y la necesidad de...

OBJECTIVE: The purpose of this study is to define the factors that condition complications and mortality in a group of 119 patients with periampullary neoplasms operated on at a general hospital. MATERIALS & METHOD: Between October 2002 and December 2006, 119 patients who were diagnosed with periampullary neoplasms and underwent a pancreatoduodenectomyat Rebagliati Hospital were evaluated. RESULTS: Age and sex were not conditioning factors of complications. A significant difference in the type of pancreatic anastomosis used was noticed, whereby telescopingwas a conditioning factor of complication (p<0.009) compared with mucous-mucous anastomosis. After analyzing the bleeding associated with each complication, a significant connection was established between the greatest bleeding volume obtained in the operating room with the development of pancreatic fistulas (p<0.03), re-operation (p<0.01), abscesses (p<0.006) and intestinal fistulas (p<0.001). The complications related to mortality in patients who underwent a pancreatoduodenectomy (PD) were evaluated. It was observed that pancreatic fistulas (p<0.003), intestinal fistulas (p<0.003) and gallbladder fistulas (p<0.03), intra-abdominal hemorrhaging and bleeding during a standard operating procedure (SOP), transfusions and re-operations were factors that increased mortality significantly. When the surgeon was evaluated as a factor of morbimortality, it was proven that there was a connection between the surgical volume and the incidence of complications andmortality. There was a shorter hospital stay, a lower incidence of intra-operative bleeding and lower morbimortality in the high surgical volume group.CONCLUSIONS: The most-feared complications, since they are directly related to mortality, are intestinal fistulas, intra-abdominal hemorrhaging, intra-abdominal abscesses,gallbladder fistulas and the need to undergo repeated operations. Both complications and mortality are directly related to the...

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