Toma de decisiones en la práctica clínica: Propuesta de un enfoque basado en evidencia “4E”

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 decisions that promote "equity" when these interventions are 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.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

Fungal biofilm associated with long-term central venous access device: Complications and therapeutic difficulties

Fungal infections associated with biofilms in biomedical devices are refractory to antifungal treatment and usually require the timely removal of the device, as well as the administration of systemic antifungals. We present the case of a 36-yearold female patient who received pain therapy administered by a Port-A-Cath long-term central venous access device. She developed catheter-related candidemi a and endocarditis caused by Candida parapsilosis. The catheter had to be removed by thoracotomy due to persistent infection despite the systemic antifungal therapy. An extensive biofilm surrounding the catheter was observed and Candida parapsilosis was isolated. Six weeks of antifungal treatment with a favorable clinical evolution were completed

Burden of epilepsy in Latin America and The Caribbean: a trend analysis of the Global Burden of Disease Study 1990 – 2019.

Background: The epilepsy prevalence in Latin America and the Caribbean (LAC) had remained high over the last 20 years. Data on the burden of epilepsy are needed for healthcare planning and resource allocation. However, no systematic analysis had been performed for epilepsy burden in LAC. Methods: We extracted data of all LAC countries from the Global Burden of Disease (GBD) study from 1990 to 2019. Epilepsy burden was measured as prevalence, mortality, and disability-adjusted life-years (DALYs; defined by the sum of years of life lost [YLLs] for premature mortality and years lived with disability [YLDs]), by age, sex, year, and country. Absolute numbers, rates, and 95% uncertainty intervals were reported. We performed correlational analyses among burden metrics and Socio-demographic Index (SDI). Findings: The burden of epilepsy decreased around 20% in LAC, led by YLLs reduction. In 2019, 6·3 million people were living with active epilepsy of all causes (95% UI 5·3 - 7·4), with 3·22 million (95% UI 2·21 - 4·03) and 3·11 million (95% UI 2·21 to 4·03) cases of epilepsy with identifiable aetiology and idiopathic epilepsy, respectively. The number of DALYs represented the 9·51% (1.37 million, 95% UI 0·99 -1·86) of the global epilepsy burden in 2019. The age-standardized burden was 175·9 per 100 000 population (95% UI 119·4 - 253·3), which tend to have a bimodal age distribution (higher in the youth and elderly) and was driven by high YLDs estimates. The burden was higher in men and older adults, primarily due to high YLLs and mortality. Alcohol use was associated with 17% of the reported DALYs. The SDI estimates significantly influenced this burden (countries with high SDI have less epilepsy burden and mortality, but not prevalence or disability). Interpretation: The epilepsy burden has decreased in LAC over the past 30 years. Even though, LAC is still ranked as the third region with the highest global epilepsy burden. This reduction was higher in children, but burden and mortality increased for older adults. The epilepsy burden is disability predominant; however, the mortality-related estimates are still higher than in other regions. Alcohol consumption and countries’ development are important determinants of this burden. There is an urgent need to improve access to epilepsy care in LAC, particularly for older adults. Strengthening primary care with online learning and telemedicine tools, and promoting risk factors modification should be prioritized in the region. Funding: This research was self-funded by the authors

Comparación de técnicas de aprendizaje automático para la clasificación de pacientes con trastornos mentales y de comportamiento debido al consumo de psicotrópicos en la ciudad de Barranquilla

Antecedentes: El trastorno por consumo de sustancia psicoactivas contribuye a una carga sustancial mundial de enfermedad, a pesar de los continuos esfuerzos de las entidades gubernamentales para mitigar esta problemática. Este problema es uno de los campos de investigación actuales más atractivo para desarrollar modelos de aprendizaje automático. Objetivo: Este proyecto de investigación tuvo como objetivo comparar cuatro modelos de aprendizaje automático para la clasificación de pacientes con trastornos mentales y de comportamiento debido al consumo de psicotrópicos ubicados en la clase de intoxicación agudo o síndrome de dependencia en la ciudad de Barranquilla. Método: El método utilizado consistió en entrenar, validar y comparar cuatro técnicas de aprendizaje automático con bases de datos de pacientes de Barranquilla. Resultados: Los resultados revelaron que bosque aleatorio y regresión logística arrojaron la mejor precisión (72%). No obstante, red neuronal artificial es el mejor modelo para predecir la proporción de casos verdaderamente positivos entre los casos positivos detectados. Por otra parte, el mejor clasificador que predice la proporción de casos positivos que están bien detectadas es bosque aleatorio, asimismo el mejor clasificador que proporciona la más alta de casos negativo que están bien detectados es máquina de soporte vectorial. Finalmente, cabe mencionar que red neuronal artificial y bosque aleatorio son los clasificadores que mejor área bajo la curva registran con 80% cada uno. Conclusiones: En términos generales, red neuronal artificial y bosque aleatorio mostraron indicios de ser un buen clasificador para discriminar entre pacientes que potencialmente estaría en un caso de intoxicación aguda o síndrome de dependencia, obteniendo valores promedios de desempeño entre 80 y 90%.  &nbsp

Prevalence of Diabetes Mellitus and Its Associated Unfavorable Outcomes in Patients With Acute Respiratory Syndromes Due to Coronaviruses Infection: A Systematic Review and Meta-Analysis

Introduction: Only 3 types of coronavirus cause aggressive respiratory disease in humans (MERS-Cov, SARS-Cov-1, and SARS-Cov-2). It has been reported higher infection rates and severe manifestations (ICU admission, need for mechanical ventilation, and death) in patients with comorbidities such as diabetes mellitus (DM). For this reason, this study aimed to determine the prevalence of diabetes comorbidity and its associated unfavorable health outcomes in patients with acute respiratory syndromes for coronavirus disease according to virus types. Methods: Systematic review of literature in Pubmed/Medline, Scopus, Web of Science, Cochrane, and Scielo until April of 2020. We included cohort and cross-sectional studies with no restriction by language or geographical zone. The selection and extraction were undertaken by 2 reviewers, independently. The study quality was evaluated with Loney’s instrument and data were synthesized by random effects model meta-analysis. The heterogeneity was quantified using an I2 statistic. Funnel plot, Egger, and Begg tests were used to evaluate publication biases, and subgroups and sensitivity analyses were performed. Finally, we used the GRADE approach to assess the evidence certainty (PROSPERO: CRD42020178049). Results: We conducted the pooled analysis of 28 studies (n = 5960). The prevalence analysis according to virus type were 451.9 diabetes cases per 1000 infected patients (95% CI: 356.74-548.78; I2 = 89.71%) in MERS-Cov; 90.38 per 1000 (95% CI: 67.17-118.38) in SARS-Cov-1; and 100.42 per 1000 (95% CI: 77.85, 125.26 I2 = 67.94%) in SARS-Cov-2. The mortality rate were 36%, 6%, 10% and for MERS-Cov, SARS-Cov-1, and SARS-Cov-2, respectively. Due to the high risk of bias (75% of studies had very low quality), high heterogeneity (I2 higher than 60%), and publication bias (for MERS-Cov studies), we down rate the certainty to very low. Conclusion: The prevalence of DM in patients with acute respiratory syndrome due to coronaviruses is high, predominantly with MERS-Cov infection. The unfavorable health outcomes are frequent in this subset of patients. Well-powered and population-based studies are needed, including detailed DM clinical profile (such as glycemic control, DM complications, and treatment regimens), comorbidities, and SARS-Cov-2 evolution to reevaluate the worldwide prevalence of this comorbidity and to typify clinical phenotypes with differential risk within the subpopulation of DM patients.Revisión por pare

Recruitment characteristics and non-adherence associated factors of fibromyalgia patients in a randomized clinical trial : a retrospective survival analysis

Introduction: Fibromyalgia is a complex pain condition that affects mostly women. Given the disease's lack of understanding, patients report poor adherence to medication and mistrust of medical services. This study aims to describe the recruitment characteristics and non-adherence associated factors of fibromyalgia patients to an RCT. Methods: We performed a retrospective longitudinal analysis with data from our ongoing RCT. We investigated characteristics of subjects recruited, consented, and randomized. Adherence was studied using survival analysis techniques, and its associated factors were identified using Cox proportional hazards regression model. Results: 524 subjects were contacted, 269 were eligible, 61 consented and 40 subjects were randomized. Thirtyeight percent were non-adherent to the protocol with a median of visits of five. The recruitment survey reported that 90% would likely participate in RCTs, 52% had previous participation, and 19% were aware of RCTs by their physicians. Some barriers were investigator-related (staff's friendliness and receiving the results of their trial participation) and center-related (privacy-confidentiality issues and the institution's reputation), without difference between adherent and non-adherent participants. We report significant factors for non-adherence as VAS anxiety score of 5 or more (5.3 HR, p = 0.01), Body Mass Index (BMI) (0.91 HR, p = 0.041) and Quality of Life (QoL) – Personal development subdomain (0.89 HR, p = 0.046). Conclusion: Recruitment and adherence of fibromyalgia patients is a challenge; however, they seem eager to participate in RCTs. We recommend creating a comfortable, friendly and trusting environment to increase the recruitment rate. Higher anxiety, lower BMI and lower quality of life were associated with a higher attrition rate

Evidence-based guidelines and secondary meta-analysis for the use of transcranial direct current stimulation in neurological and psychiatric disorders

Background: Transcranial direct current stimulation has shown promising clinical results, leading to increased demand for an evidence-based review on its clinical effects. Objective: We convened a team of transcranial direct current stimulation experts to conduct a systematic review of clinical trials with more than 1 session of stimulation testing: pain, Parkinson’s disease motor function and cognition, stroke motor function and language, epilepsy, major depressive disorder, obsessive compulsive disorder, Tourette syndrome, schizophrenia, and drug addiction. Methods: Experts were asked to conduct this systematic review according to the search methodology from PRISMA guidelines. Recommendations on efficacy were categorized into Levels A (definitely effective), B (probably effective), C (possibly effective), or no recommendation. We assessed risk of bias for all included studies to confirm whether results were driven by potentially biased studies. Results: Although most of the clinical trials have been designed as proof-of-concept trials, some of the indications analyzed in this review can be considered as definitely effective (Level A), such as depression, and probably effective (Level B), such as neuropathic pain, fibromyalgia, migraine, post-operative patient-controlled analgesia and pain, Parkinson’s disease (motor and cognition), stroke (motor), epilepsy, schizophrenia, and alcohol addiction. Assessment of bias showed that most of the studies had low risk of biases, and sensitivity analysis for bias did not change these results. Effect sizes vary from 0.01 to 0.70 and were significant in about 8 conditions, with the largest effect size being in postoperative acute pain and smaller in stroke motor recovery (nonsignificant when combined with robotic therapy). Conclusion: All recommendations listed here are based on current published PubMed-indexed data. Despite high levels of evidence in some conditions, it must be underscored that effect sizes and duration of effects are often limited; thus, real clinical impact needs to be further determined with different study designs

Estimating mortality and disability in Peru before the COVID-19 pandemic: a systematic analysis from the Global Burden of the Disease Study 2019

"Background: Estimating and analyzing trends and patterns of health loss are essential to promote efficient resource allocation and improve Peru’s healthcare system performance. Methods: Using estimates from the Global Burden of Disease (GBD), Injuries, and Risk Factors Study (2019), we assessed mortality and disability in Peru from 1990 to 2019. We report demographic and epidemiologic trends in terms of population, life expectancy at birth (LE), mortality, incidence, prevalence, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) caused by the major diseases and risk factors in Peru. Finally, we compared Peru with 16 countries in the Latin American (LA) region. Results: The Peruvian population reached 33.9 million inhabitants (49.9% women) in 2019. From 1990 to 2019, LE at birth increased from 69.2 (95% uncertainty interval 67.8–70.3) to 80.3 (77.2–83.2) years. This increase was driven by the decline in under-5 mortality (−80.7%) and mortality from infectious diseases in older age groups (+60 years old). The number of DALYs in 1990 was 9.2 million (8.5–10.1) and reached 7.5 million (6.1–9.0) in 2019. The proportion of DALYs due to non-communicable diseases (NCDs) increased from 38.2% in 1990 to 67.9% in 2019. The all-ages and age-standardized DALYs rates and YLLs rates decreased, but YLDs rates remained constant. In 2019, the leading causes of DALYs were neonatal disorders, lower respiratory infections (LRIs), ischemic heart disease, road injuries, and low back pain. The leading risk factors associated with DALYs in 2019 were undernutrition, high body mass index, high fasting plasma glucose, and air pollution. Before the COVID-19 pandemic, Peru experienced one of the highest LRIs-DALYs rates in the LA region. Conclusion: In the last three decades, Peru experienced significant improvements in LE and child survival and an increase in the burden of NCDs and associated disability. The Peruvian healthcare system must be redesigned to respond to this epidemiological transition. The new design should aim to reduce premature deaths and maintain healthy longevity, focusing on effective coverage and treatment of NCDs and reducing and managing the related disability.

Clinical practice guideline for the management of atrial fibrillation for the Peruvian Social Security (EsSalud)

Introducción. El presente artículo resume la guía de práctica clínica (GPC) para el manejo de pacientes con fibrilación auricular (FA) en el Seguro Social del Perú (EsSalud). Objetivo. Proveer recomendaciones clínicas basadas en evidencia para el manejo de pacientes con FA en EsSalud. Métodos. Se conformó un grupo elaborador (GEG) que incluyó médicos especialistas y metodólogos. El GEG formuló 9 preguntas clínicas a ser respondidas por la presente GPC. Se realizó búsquedas sistemáticas de revisiones sistemáticas y ,cuando fue considerado pertinente, estudios primarios en Medline durante el 2017. Se seleccionó la evidencia para responder cada una de las preguntas clínicas planteadas. La certeza de la evidencia fue evaluada usando la metodología Grading of Recommendations Assessment, Development, and Evaluation (GRADE). En reuniones de trabajo periódicas, el GEG usó la metodología GRADE para revisar la evidencia y formular las recomendaciones, los puntos de buenas prácticas clínicas y los flujogramas de la GPC. Finalmente, la GPC fue aprobada con Resolución N° 91 – IETSI – ESSALUD – 2018. Resultados. La presente GPC abordó 9 preguntas clínicas, divididas en tres temas: prevención de eventos tromboembólicos, estrategias de control y manejo de FA en emergencias. En base a dichas preguntas se formularon 12 recomendaciones (6 recomendaciones fuertes y 6 recomendaciones condicionales), 29 puntos de buena práctica clínica, y 2 algoritmos. Conclusión. El presente artículo resume la metodología y las conclusiones basadas en evidencias de la GPC para manejo de pacientes con FA en EsSalud.Abstract. This article summarizes the clinical practice guide (CPG) for the management of patients with atrial fibrillation (AF) in the Social Security of Peru (EsSalud). Objective. To provide clinical recommendations based on evidence for the management of patients with AF in EsSalud. Methods. A CPG for the management of patients with AF in EsSalud was developed. To this end, a guideline development group (GDG) was established, including medical specialists and methodologists. The GDG formulated 9 clinical questions to be answered by this CPG. Systematic searches of systematic reviews and ,when it was considered pertinent, primary studies were conducted in Medline during 2017. The evidence to answer each of the posed clinical questions was selected. The quality of the evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. In periodic work meetings, the GDG used the GRADE methodology to review the evidence and formulate the recommendations, points of good clinical practice, and the flowchart of the CPG. Finally, the CPG was approved with Resolution No. 91 – IETSI – ESSALUD – 2018. Results. This CPG addressed 9 clinical questions, divided into three topics: prevention of thromboembolic events, maintenance therapy and management of AF. Based on these questions, 12 recommendations (6 strong recommendations and 6 weak recommendations), 29 points of good clinical practice, and 2 algorithms were formulated. Conclusion. This article summarizes the methodology and evidence-based conclusions from the CPG for the management of AF in EsSalud

Using a Taxonomy to Systematically Identify and Describe Self-Management Interventions Components in Randomized Trials for COPD

Self-management interventions (SMIs) may improve outcomes in Chronic Obstructive Pulmonary Disease (COPD). However, accurate comparisons of their relative effectiveness are challenging, partly due to a lack of clarity and detail regarding the intervention content being evaluated. This study systematically describes intervention components and characteristics in randomized controlled trials (RCTs) related to COPD self-management using the COMPAR-EU taxonomy as a framework, identifying components that are insufficiently incorporated into the design of the intervention or insufficiently reported. Overall, 235 RCTs published between 2010 and 2018, from a systematic review were coded using the taxonomy, which includes 132 components across four domains: intervention characteristics, expected patient (or caregiver) self-management behaviours, patient relevant outcomes, and target population characteristics. Risk of bias was also assessed. Interventions mainly focused on physical activity (67.4%), and condition-specific behaviours like breathing exercise (63.5%), self-monitoring (50.8%), and medication use (33.9%). Support techniques like education and skills-training, self-monitoring, and goal setting (over 35% of the RCTs) were mostly used for this. Emotional-based techniques, problem-solving, and shared decision-making were less frequently reported (less than 15% of the studies). Numerous SMIs components were insufficiently incorporated into the design of COPD SMIs or insufficiently reported. Characteristics like mode of delivery, intensity, location, and providers involved were often not described. Only 8% of the interventions were tailored to the target population's characteristics. Outcomes that are considered important by patients were hardly taken into account. There is still a lot to improve in both the design and description of SMIs for COPD. Using a framework such as the COMPAR-EU SMI taxonomy may contribute to better reporting and to better informing of replication efforts. In addition, prospective use of the taxonomy for developing and reporting intervention content would further aid in building a cumulative science of effective SMIs in COPD