Analysis of Latin American scientific output in medicine

En la última década se produjo un aumento del gasto en investigación en países en vías de desarrollo. Ante la ausencia de análisis recientes, decidimos evaluar la producción científica en medicina de Latinoamérica y su correlación con variables demográficas y económicas. Analizamos el número total de documentos producidos en cada país y su índice H. Realizamos un subanálisis de los 4 países con mayor índice H y analizamos la correlación existente entre la población de cada país, su PBI y el gasto en investigación. Brasil está en primer lugar en relación con el índice H y número total de documentos, seguido por la Argentina y México, en ese orden. El crecimiento de documentos publicados fue de 530% para Brasil, 331% para Chile, 267% para Argentina y 239% para México. Los 4 países presentaron aumentos de su participación en la producción mundial. Brasil presenta mayor inversión porcentual destinada a investigación, comparado con Argentina y México, mientras que la Argentina supera en inversión porcentual a México. Brasil, Argentina, México y Chile lideran la producción científica médica regional, con importante crecimiento de su producción. Este crecimiento podría encontrarse asociado a la situación económica regional y al aumento observado de la inversión en investigación. La influencia de la región a nivel mundial se encuentra en aumento aunque continúa siendo limitada.Introduction. Over the last decade the global spending on research, the number of researchers and the number of scientific publications have been markedly increased. This increment was especially significant in developing countries. Therefore, considering the absence of recent evaluations, we decided to study the scientific output of Argentina in medicine as compared with other Latin American countries as well as the possible correlations between scientific output and demographics or economical variables. Methods. The countries included in our study were: Argentina, Bolivia, Brasil, Chile, Colombia, Ecuador, Mexico, Paraguay, Peru, Uruguay and Venezuela. We analyzed the total number of documents produced in each country for the period 1996-2010 and its H index, in the category “medicine” and within the categories available for each specialty. Then, we performed a sub-analysis of the 4 countries with the highest H index and analyzed the correlation between the population of each country, GDP and the research expenditures. Results. Brazil ranks first in relation to the H index and total number of papers published, followed by Argentina and Mexico respectively. The increase of papers published between 1996 and 2010 was of 530% for Brazil, 331% for Chile, 267 % for Argentina and 239% for Mexico. The 4 four countries increased their share in total world production. Brazil presents a higher research spending, as compared with Argentina and Mexico, while Argentina investment exceeds the Mexican. The GDP showed significant correlations with the H index and the total number of produced documents by each country. Conclusion. Brazil, Argentina, Mexico and Chile lead the regional scientific output and presented considerable increments in their production over the past fifteen years. This growth may be associated with the regional economic situation and the observed increase investment in research and development. Moreover, the influence of the region in global production is increasing but still limited.Fil: Mc Loughlin, Santiago. Centro Médico Florida; ArgentinaFil: Rodriguez Granillo, Gaston Alfredo. Sanatorio "Otamendi y Miroli S. A."; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentin

Sociedade ERAS e América Latina

The volume of surgeries and their complexity has been increasing steadily worldwide. In our region, this demand is not resolved in quantity or quality and the lack of register of the care process leads to great misspending of funds, time and energy from health systems and their professionals. The goal of ERAS® (Enhanced Recovery After Surgery) is to develop perioperative care and improve its recovery through research, education, auditing and implementation of evidence-based practices. Systematically registration of the care process, actions based on accurate diagnosis and, finally, audit and adjustments of the actions are the working principles common to all ERAS® protocols. The different stages of surgical care are approached by a multidisciplinary team as an indivisible process that constitutes perioperative care. This team works week by week using the ERAS Society data management system that provides a registry with variables globally standardized that allow internal audit and external comparison. The implementation of ERAS® programs in Europe and North America showed significant reductions in hospital stay, postoperative complications and costs of care. At a regional level, the ERAS® protocols have expanded to 6 countries and 10 centers with results similar to those reported in the rest of the world. A major change in perioperative care is underway in the region, and our goal is to make it available to  everyone.El volumen de cirugías y su complejidad aumenta de forma constante en el mundo. En nuestra región, esta demanda no resuelta, ni en cantidad ni en calidad de atención, además de la deficiencia en el registro del proceso de cuidado conduce a grandes desperdicios de dinero, tiempo y energía de los sistemas de salud y sus profesionales. Los objetivos de ERAS® (Enhanced Recovery After Surgery) incluyen desarrollar el cuidado perioperatorio y mejorar su recuperación a través de la investigación, educación, auditoría e implementación de prácticas basadas en la evidencia. Registrar sistemáticamente el proceso de cuidado, actuar con base en el diagnóstico y, por último, auditar y ajustar las acciones constituyen los principios de trabajo común a todos los protocolos ERAS®. Las diferentes etapas de la atención quirúrgica son abordadas como un proceso indivisible que constituye la atención perioperatoria a través de un equipo multidisciplinario. Este equipo trabaja semana a semana utilizando el sistema de gestión de datos de ERAS Society que provee un registro con variables estandarizadas mundialmente lo que permite la auditoría interna y la comparación externa. La implementación de programas ERAS® demostró, en el ámbito mundial, reducciones significativas en la estancia hospitalaria, complicaciones postoperatorias y los costos de atención. En el ámbito regional los protocolos ERAS® se han expandido estando al momento presentes en 6 países y 10 centros de atención con resultados similares a los reportados en el mundo. Un gran cambio en el cuidado perioperatorio está en marcha en la región, y nuestro objetivo, es hacer que esté disponible para todos.O volume de cirurgias e sua complexidade aumenta constantemente no mundo. Na nossa região, essa procura não atendida, nem em quantidade nem em qualidade de assistência, além de uma deficiência no registro do processo de assistência, gera grande desperdício de dinheiro, tempo e energia nos sistemas de saúde e nos seus profissionais. Os objetivos do ERAS® (Enhanced Recovery After Surgery) incluem o desenvolvimento de cuidados perioperatórios e a melhoria da recuperação por meio de pesquisa, educação, auditoria e implementação de práticas baseadas em evidências. Registar sistematicamente o processo de cuidar, atuar com base no diagnóstico e por fim auditar e ajustar os procedimentos, constituem os princípios de trabalho comuns a todos os protocolos ERAS®. As diferentes etapas do atendimento cirúrgico são abordadas como um processo indivisível que constitui o cuidado perioperatório por meio de uma equipe multidisciplinar. Essa equipe trabalha semana após semana usando o sistema de gestão de dados da Sociedade ERAS, que fornece um registo com variáveis estandardizadas mundialmente, o que permite uma auditoria interna e a comparação externa. A implementação dos programas ERAS® demonstrou, em todo o mundo, reduções significativas no tempo de internamento hospitalar, nas complicações pós-operatórias e nos custos com os cuidados. A nível regional, os protocolos ERAS® se expandiram estando neste momento presentes em 6 países e 10 centros de atendimento com resultados semelhantes aos relatados pelo mundo. Uma grande mudança no atendimento perioperatório está em andamento na região, e o nosso objetivo é que esteja disponível para todos

C-section on patient with secondary paraplegia resulting from spontaneous spinal epidural hematoma and acquired FXIII deficiency. A case report

Background: Spontaneous spinal epidural hematoma (SSEH) in a pregnant patient is an extremely rare clinical condition and requires emergency surgical evacuation, while termination of pregnancy depends on fetal viability status1 . Etiology includes hemorrhagic diathesis, autoimmune inflammatory vasculitis, anticoagulant therapy, vascular malformations, and tumors. Pregnancy is considered a risk factor for SSEH. Below is a patient with SSEH and acquired FXIII deficiency (FXIII D) as a sole finding. Case report: A 37 year old, gravida 3 para 2, 28 weeks of gestation was transferred to our hospital with symptoms of progressive paraplegia over 72 hours. MRI showed spinal lesion due to spontaneous epidural hematoma, emergency decompression followed with a T1-T5 laminectomy. A hemorrhagic episode required transfusions up to 4 RBCs and 2 FFPs during the laminectomy, neither FXIII nor Tranexamic acid (TXA) was given on that occasion. The neurological examination showed flaccid paraplegia, with sensitive level at T3. Test results showed normal values except in FXIII-A concentration 28% (60-160%). No other major bleeding cause could be determined aside from the FXIII D. Two months later, she had a c-section performed at 36 weeks of gestation. Intravenous plasma-derived FXIII (pdFXIII) concentrate 2500 IU was given preoperatively along with TXA 1g. General anesthesia using propofol for induction and sevorane for maintenance was administered, no muscle relaxants or opioids were necessary. Videolaryngoscopy was used for orotracheal intubation. Bleeding was between normal ranges. There was no need for RBC transfusions. A healthy female baby was born with a 8/9 Apgar score and 2,840 grams. Post-operative FXIII-A level was 69%. Discussion: There are merely a few dozens of pregnant SSEH cases reported in the literature. Regional anesthesia for paraplegic condition is advised as the best technique to prevent autonomic dysreflexia; although general anesthesia seems more appropriate to prevent further spinal complications in patients with hemorrhagic diathesis2 . References: 1. Krishnan P, et al. Neurol India. 2014;62(2):205-7. 2. Jones BP, et al. Can J Anaesth. 2000;47(11):1122-28. Learning points: General anesthesia is an adequate anesthesia technique for paraplegic patients with FXIIID. FXIII should be tested even if coagulation test results are normal, and preoperative pdFXIII administration is probably the best way to prevent severe bleeding as well as TXA in these patients

Rate of atherosclerosis progression in ApoE-/- mice long after discontinuation of cola beverage drinking.

This study was conducted in order to evaluate the effect of cola beverages drinking on atherosclerosisand test the hypothesis whether cola beverages consumption at early life stages might affect the development and progression of atherosclerosis later in life. ApoE-/- C57BL/6J mice (8 week-old) were randomized in 3 groups (n = 20 each) according to free accessto water (W), sucrose sweetened carbonated cola drink(C) or aspartame-acesulfame K sweetened carbonated 'light' cola drink (L)for the next 8 weeks. Drinking treatment was ended by switching C and L groups to drinking water. Four mice per group and time were sequentially euthanized: before treatment (8 weeks-old), at the end of treatment (16 weeks-old) and after treatment discontinuation (20 weeks-old, 24 weeks-old, 30 week-old mice). Aortic roots and livers were harvested, processed for histology and serial cross-sections were stained. Aortic plaque area was analyzed and plaque/media-ratio was calculated. Early consumption of cola drinks accelerated atherosclerotic plaque progression favoring the interaction between macrophages and myofibroblasts, without the participation of either T lymphocytes or proliferative activity. Plaque/media-ratio varied according to drink treatment (F2,54 = 3.433, p<0.04) and mice age (F4,54 = 5.009, p<0.03) and was higher in C and L groups compared with age-matched W group (p<0.05 at 16 weeks and 20 weeks, p<0.01 at 24 weeks and 30 weeks). Natural evolution of atherosclerosis in ApoE-/- mice (W group) evidenced atherosclerosis acceleration in parallel with a rapid increase in liver inflammation around the 20 weeks of age. Cola drinking within the 8-16 weeks of age accelerated atherosclerosis progression in ApoE-/- mice favoring aortic plaque enlargement (inward remodeling) over media thinning all over the study time. Data suggest that cola drinking at early life stages may predispose to atherosclerosis progression later in life in ApoE-/- mice

Effect of cola beverages drinking on the population of CD68 positive macrophages (Mo) and α-SMA myofibroblasts (Mf) in atherosclerotic plaques in Apo E^−/− mice over the study time.

<p>Values are expressed as the mean percentage oftotal plaque area occupied by either CD68 positive macrophages (Mo) or smooth muscle α-actin positive myofibroblasts (Mf). # p<0.001 compared with W.</p

Effect of cola beverages drinking on the population of CD68 positive macrophages (Mo) and α-SMA myofibroblasts (Mf) in atherosclerotic plaques in Apo E^−/− mice over the study time.

<p>Values are expressed as the mean percentage oftotal plaque area occupied by either CD68 positive macrophages (Mo) or smooth muscle α-actin positive myofibroblasts (Mf). # p<0.001 compared with W.</p

Representative immunohistochemical staining for CD68 and α-smooth muscle actin (α-SMA) illustrating cellular populations involved in plaque formation.

<p>A: cytoplasmic immunostaining for CD68 in subendothelial foamy macrophages in 16 week-old mice; B: cholesterol crystals (C), aortic media layer (M) and cytoplasmic expression of α-smooth muscle actin in myofibroblasts (Mf) in 20–24 week-old mice; C: macrophages (Mo) and globular accumulations of lipids in 20–24 week-old mice (C). Original magnification 400×.</p

Natural evolution of plaque area and liver inflammation in Apo E^−/− mice (water drinking) over time.

<p>Natural evolution of plaque area and liver inflammation in Apo E^−/− mice (water drinking) over time.</p

Effect of cola beverages drinking on plaque/media-ratio in ApoE^−/− mice over the study time.

<p>Inset table shows individual plaque area and media thickness values used to calculate plaque/media-ratio which is plotted in the main graph. *p<0.05, # p<0.01 compared with W.</p