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Our objective was to determine the factors associated with the successful maturation of arteriovenous fistulas during hemodialysis.

The relationship between economic globalization and University Education based on competences is analyzed. A diversity of uses for the term “competence” in the education literature is presented. From an interbehavioral perspective, different attributes for the concept of “competence” are analyzed. A contrast is made between the basic features of traditional-education with a proposal for education based on competences in relation to the present socioeconomic conditions

Importance: Hyponatremia treatment guidelines recommend limiting the correction of severe hyponatremia during the first 24 hours to prevent osmotic demyelination syndrome (ODS). Recent evidence suggests that slower rates of correction are associated with increased mortality., Objective: To evaluate the association of sodium correction rates with mortality among hospitalized adults with severe hyponatremia., Data Sources: We searched MEDLINE, Embase, the Cochrane Library, LILACS, Web of Science, CINAHL, and international congress proceedings for studies published between January 2013 and October 2023., Study Selection: Comparative studies assessing rapid (≥8-10 mEq/L per 24 hours) vs slow (<8 or 6-10 mEq/L per 24 hours) and very slow (<4-6 mEq/L per 24 hours) correction of severe hyponatremia (serum sodium <120 mEq/L or <125 mEq/L plus severe symptoms) in hospitalized patients., Data Extraction and Synthesis: Pairs of reviewers (N.A.F., J.R.M., J.M.A., A.C.) independently reviewed studies, extracted data, and assessed each included study's risk of bias using ROBINS-I. Cochrane methods, PRISMA reporting guidelines, and the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to rate the certainty of evidence were followed. Data were pooled using a random-effects model., Main Outcomes and Measures: Primary outcomes were in-hospital and 30-day mortality, and secondary outcomes were hospital length of stay (LOS) and ODS., Results: Sixteen cohort studies involving a total of 11 811 patients with severe hyponatremia were included (mean [SD] age, 68.22 [6.88] years; 56.7% female across 15 studies reporting sex). Moderate-certainty evidence showed that rapid correction was associated with 32 (odds ratio, 0.67; 95% CI, 0.55-0.82) and 221 (odds ratio, 0.29; 95% CI, 0.11-0.79) fewer in-hospital deaths per 1000 treated patients compared with slow and very slow correction, respectively. Low-certainty evidence suggested that rapid correction was associated with 61 (risk ratio, 0.55; 95% CI, 0.45-0.67) and 134 (risk ratio, 0.35; 95% CI, 0.28-0.44) fewer deaths per 1000 treated patients at 30 days and with a reduction in LOS of 1.20 (95% CI, 0.51-1.89) and 3.09 (95% CI, 1.21-4.94) days, compared with slow and very slow correction, respectively. Rapid correction was not associated with a statistically significant increased risk of ODS., Conclusions and Relevance: In this systematic review and meta-analysis, slow correction and very slow correction of severe hyponatremia were associated with an increased risk of mortality and hospital LOS compared to rapid correction.

Objective: To compare the effectiveness of the awake-prone position on relevant clinical outcomes in patients with COVID-19-related acute respiratory failure requiring high-flow nasal oxygen between different waves in Argentina., Methods: This multicenter, prospective cohort study included adult patients with COVID-19-related acute respiratory failure requiring high-flow nasal oxygen. The main exposure position was the awake-prone position (≥ 6 hours/day) compared to the non-prone position. The primary outcome was endotracheal intubation, and the secondary outcome was in-hospital mortality. The inverse probability weighting-propensity score was used to adjust the conditional probability of treatment assignment. We then adjusted for contextual variables that varied over time and compared the effectiveness between the first and second waves., Results: A total of 728 patients were included: 360 during the first wave and 368 during the second wave, of whom 195 (54%) and 227 (62%) remained awake-prone for a median (p25 - 75) of 12 (10 - 16) and 14 (8 - 17) hours/day, respectively (Awake-Prone Position Group). The ORs (95%CIs) for endotracheal intubation in the Awake-Prone Position Group were 0.25 (0.13 - 0.46) and 0.19 (0.09 - 0.31) for the first and second waves, respectively (p = 0.41 for comparison between waves). The ORs for in-hospital mortality in the awake-prone position were 0.35 (0.17 - 0.65) and 0.22 (0.12 - 0.43), respectively (p = 0.44 for comparison between waves)., Conclusion: The awake-prone position was associated with a reduction in the risk of endotracheal intubation and in-hospital mortality. These effects were independent of the context in which the intervention was applied, and no differences were observed between the different waves.

Objectives: The Berlin definition of acute respiratory distress syndrome (ARDS) was constructed for patients receiving invasive mechanical ventilation (IMV) with consideration given to issues related to reliability, feasibility, and validity. Notwithstanding, patients with acute respiratory failure (ARF) may be treated with high-flow nasal oxygen (HFNO) and may not fall within the scope of the original definition. We aimed to evaluate the predictive validity of the Berlin definition in HFNO-treated patients with COVID-19-related respiratory failure who otherwise met ARDS criteria., Design: Multicenter, prospective cohort study., Setting: Five ICUs of five centers in Argentina from March 2020 to September 2021., Patients: We consecutively included HFNO-treated patients older than 18 years with confirmed COVID-19-related ARF, a Pa o2 /F io2 of less than 300 mm Hg, bilateral infiltrates on imaging, and worsening respiratory symptoms for less than 1 week., Interventions: None., Measurements and Main Results: We evaluated the predictive validity of mortality at day 28 using the area under the receiver operating characteristics curve (AUC), compared the predictive validity across subgroups, and characterized relevant clinical outcomes. We screened 1,231 patients and included 696 ARDS patients [30 (4%) mild, 380 (55%) moderate, and 286 (41%) severe]. For the study cohort, the AUC for mortality at day 28 was 0.606 (95% CI, 0.561-0.651) with the AUC for subgroups being similar to that of the overall cohort. Two hundred fifty-six patients (37%) received IMV. By day 28, 142 patients (21%) had died, of whom 81 (57%) had severe ARDS. Mortality occurred primarily in patients who were transitioned to IMV., Conclusions: The predictive validity of the Berlin ARDS definition was similar for HFNO-treated patients as compared with the original population of invasively ventilated patients. Our findings support the extension of the Berlin definition to HFNO-treated patients with ARDS., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Background and Goal of Study: Pulse pressure variation (PPV) and stroke volume variation (SVV), which are based on the forces caused by controlled mechanical ventilation, are commonly used to predict fluid responsiveness. When PPV and SVV were introduced into clinical practice, volume-controlled ventilation (VCV) with tidal volumes (VT) ≥ 10 ml kg - 1 was most commonly used. Nowadays, lower VT and the use of pressure-controlled ventilation (PCV) has widely become the preferred type of ventilation. Due to their specific flow characteristics, VCV and PCV result in different airway pressures at comparable tidal volumes. We hypothesised that higher inspiratory pressures would result in higher PPVs and aimed to determine the impact of VCV and PCV on PPV and SVV., Methods: In this self-controlled animal study, sixteen anaesthetised, paralysed, and mechanically ventilated (goal: VT 8 ml kg - 1 ) pigs were instrumented with catheters for continuous arterial blood pressure measurement and transpulmonary thermodilution. At four different intravascular fluid states (IVFS; baseline, hypovolaemia, resuscitation I and II), ventilatory and hemodynamic data including PPV and SVV were assessed during VCV and PCV. Statistical analysis was performed using U-test and RM ANOVA on ranks as well as descriptive LDA and GEE analysis., Results: Complete data sets were available of eight pigs. VT and respiratory rates were similar in both forms. Heart rate, central venous, systolic, diastolic, and mean arterial pressures were not different between VCV and PCV at any IVFS. Peak inspiratory pressure was significantly higher in VCV, while plateau, airway and transpulmonary driving pressures were significantly higher in PCV. However, these higher pressures did not result in different PPVs nor SVVs at any IVFS., Conclusion: VCV and PCV at similar tidal volumes and respiratory rates produced PPVs and SVVs without clinically meaningful differences in this experimental setting. Further research is needed to transfer these results to humans., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Introduction: Restless legs syndrome (RLS) is a disorder characterised by an irresistible urge to move the legs, usually accompanied by unpleasant sensations. It is more frequent in patients with multiple sclerosis (MS) than in the general population., Objectives: To evaluate the prevalence of RLS, defined according to the 4 essential requirements included in the diagnostic criteria proposed by the International Restless Leg Syndrome Study Group, in a cohort of patients with MS; and to identify potential risk factors and the clinical impact of RLS., Results: The sample included 120 patients with MS, with a mean age of symptom onset of 40 years and an average disease duration of 46 months. The prevalence rate of RLS was 23.3%. MS progression time was significantly shorter in patients with RLS (P=.001). A recent relapse, and symptoms of anxiety, depression, and neuropathic pain were significantly associated with risk of RLS (P=.001, P<.001, P<.001, and P=.001, respectively). In addition, patients with RLS had a greater risk of poor sleep quality, fatigue, daytime sleepiness, and poor quality of life than those without RLS (P=.002, P=.017, P=.013, and P=.009, respectively)., Conclusions: RLS should be considered in the neurological evaluation of patients with MS; early diagnosis and treatment would improve the quality of life of patients with MS presenting RLS., (Copyright © 2019 Sociedad Española de Neurología. Published by Elsevier España, S.L.U. All rights reserved.)

Background: In patients with COVID-19-related acute respiratory failure (ARF), awake prone positioning (AW-PP) reduces the need for intubation in patients treated with high-flow nasal oxygen (HFNO). However, the effects of different exposure times on clinical outcomes remain unclear. We evaluated the effect of AW-PP on the risk of endotracheal intubation and in-hospital mortality in patients with COVID-19-related ARF treated with HFNO and analyzed the effects of different exposure times to AW-PP., Methods: This multicenter prospective cohort study in six ICUs of 6 centers in Argentine consecutively included patients > 18 years of age with confirmed COVID-19-related ARF requiring HFNO from June 2020 to January 2021. In the primary analysis, the main exposure was awake prone positioning for at least 6 h/day, compared to non-prone positioning (NON-PP). In the sensitivity analysis, exposure was based on the number of hours receiving AW-PP. Inverse probability weighting-propensity score (IPW-PS) was used to adjust the conditional probability of treatment assignment. The primary outcome was endotracheal intubation (ETI); and the secondary outcome was hospital mortality., Results: During the study period, 580 patients were screened and 335 were included; 187 (56%) tolerated AW-PP for [median (p25-75)] 12 (9-16) h/day and 148 (44%) served as controls. The IPW-propensity analysis showed standardized differences < 0.1 in all the variables assessed. After adjusting for other confounders, the OR (95% CI) for ETI in the AW-PP group was 0.36 (0.2-0.7), with a progressive reduction in OR as the exposure to AW-PP increased. The adjusted OR (95% CI) for hospital mortality in the AW-PP group ≥ 6 h/day was 0.47 (0.19-1.31). The exposure to prone positioning ≥ 8 h/d resulted in a further reduction in OR [0.37 (0.17-0.8)]., Conclusion: In the study population, AW-PP for ≥ 6 h/day reduced the risk of endotracheal intubation, and exposure ≥ 8 h/d reduced the risk of hospital mortality., (© 2022. The Author(s).)

BACKGROUND: Stress-induced hyperglycemia is a phenomenon that occurs typically in patients hospitalized for acute disease and resolves spontaneously after regression of the acute illness. However, it can also occur in diabetes patients, a fact that is sometimes overlooked. It is thus important to make a proper diabetes diagnosis if hospitalized patients with episodes of hyperglycemia with and without diabetes are studied. AIMS: To estimate the extent of the association between stress-induced hyperglycemia and in-hospital mortality in patients with hospital hyperglycemia (HH), and to explore potential differences between patients diagnosed with diabetes (HH-DBT) and those with stress-induced hyperglycemia (SH), but not diagnosed with diabetes. METHODS: A cohort of adults with hospital hyperglycemia admitted to a tertiary, university hospital in Buenos Aires, Argentina, was analyzed retrospectively. RESULTS: In the study, 2,955 patients were included and classified for analysis as 1,579 SH and 1,376 HH-DBT. Significant differences were observed in glycemic goal (35.53% SH versus 25.80% HH-DBT, p < 0.01), insulin use rate (26.66% SH versus 46.58% HH-DBT, p < 0.01), and severe hypoglycemia rate (1.32% SH versus 1.74% HH-DBT, p < 0.01). There were no differences in hypoglycemia rate (8.23% SH versus 10.53% HH-DBT) and hospital mortality. There was no increase in risk of mortality in the SH group adjusted for age, non-scheduled hospitalization, major surgical intervention, critical care, hypoglycemia, oncological disease, cardiovascular comorbidity, and prolonged hospitalization. CONCLUSIONS: In this study, we observed better glycemic control in patients with SH than in those with HH-DBT, and there was no difference in hospital mortality.

Background: Convalescent plasma is frequently administered to patients with Covid-19 and has been reported, largely on the basis of observational data, to improve clinical outcomes. Minimal data are available from adequately powered randomized, controlled trials., Methods: We randomly assigned hospitalized adult patients with severe Covid-19 pneumonia in a 2:1 ratio to receive convalescent plasma or placebo. The primary outcome was the patient's clinical status 30 days after the intervention, as measured on a six-point ordinal scale ranging from total recovery to death., Results: A total of 228 patients were assigned to receive convalescent plasma and 105 to receive placebo. The median time from the onset of symptoms to enrollment in the trial was 8 days (interquartile range, 5 to 10), and hypoxemia was the most frequent severity criterion for enrollment. The infused convalescent plasma had a median titer of 1:3200 of total SARS-CoV-2 antibodies (interquartile range, 1:800 to 1:3200). No patients were lost to follow-up. At day 30 day, no significant difference was noted between the convalescent plasma group and the placebo group in the distribution of clinical outcomes according to the ordinal scale (odds ratio, 0.83; 95% confidence interval [CI], 0.52 to 1.35; P = 0.46). Overall mortality was 10.96% in the convalescent plasma group and 11.43% in the placebo group, for a risk difference of -0.46 percentage points (95% CI, -7.8 to 6.8). Total SARS-CoV-2 antibody titers tended to be higher in the convalescent plasma group at day 2 after the intervention. Adverse events and serious adverse events were similar in the two groups., Conclusions: No significant differences were observed in clinical status or overall mortality between patients treated with convalescent plasma and those who received placebo. (PlasmAr ClinicalTrials.gov number, NCT04383535.)., (Copyright © 2020 Massachusetts Medical Society.)

Background: Nonattendance to scheduled appointments in outpatient clinics is a frequent problem in ambulatory medicine with an impact on health systems and patients' health. The characterization of nonattendance is fundamental for the design of appropriate strategies for its management., Aims: To identify causes of nonattendance of scheduled ambulatory medical appointments by adult patients., Methods: Case and two controls study nested in a prospective cohort. A telephone-administered questionnaire was applied within the first 72 hours to identify the causes of attendance, nonattendance, or cancellation in patients who had a scheduled appointment to which they had been present, absent, or cancelled., Results: A total of 150 absences (cases), 176 attendances, and 147 cancellations (controls) in a prospective cohort of 160 146 scheduled appointments (2012/2013) were included. According to self-reports in telephone interviews, the most frequent causes of nonattendance were forgetting 44% (66), unexpected competing events 15.3% (23), illness or unwellness 12% (18), work-related inconvenience 5.3% (8), transport-related difficulties 4.7% (4), and cause that motivated appointment scheduling already resolved 4.7% (4)., Discussion: The main cause of nonattendance is forgetting the scheduled appointment, but there is a proportion of different causes that do not respond to reminders but could respond to different strategies., (© 2019 John Wiley & Sons, Ltd.)

Introducción: No hay datos recientes en México sobre el estado de los médicos especialistas que permitan diseñar políticas de formación y empleo de los recursos humanos para la salud., Objetivo: Analizar el estado actual de los médicos especialistas en México: número, distribución (geográfica, por sexo y especialidad), vigencia de la certificación (por sexo y especialidad) y tasa de especialistas por 100 000 habitantes., Método: estudio transversal descriptivo. Se consultaron múltiples fuentes disponibles en México: consejos, asociaciones, colegios, instituciones hospitalarias, universidades y otros., Resultados: Se contabilizaron 147 910 especialistas para una población de 123 518 272 habitantes; 69 % contaba con certificación vigente de la especialidad. Se obtuvo una tasa de 119 especialistas por 100 000 habitantes; 54.2 % se encontraba en la Ciudad de México, Estado México, Jalisco y Nuevo León. En promedio había 1.7 especialistas varones por cada mujer., Conclusiones: El número de especialistas es inferior al recomendado internacionalmente e insuficiente para cubrir las necesidades en salud del país. La distribución por género está cambiando hacia una más equitativa. Los especialistas están agrupados mayormente en zonas urbanas. Es el primer censo de especialistas con base en el número comprobable de médicos, que permitirá el diseño de políticas de planificación de recursos humanos en salud., Introduction: There are no recent data in Mexico about the state of medical specialists that allow the design of policies for training and use of human resources for health., Objective: To analyze the current state of medical specialists in Mexico: number, distribution (geographical, by gender and specialty), certification validity (by gender and specialty) and the rate of specialists per 100 000 population., Method: Cross-sectional, descriptive study. Multiple sources available in Mexico were consulted: councils, associations, schools, hospital institutions, universities, and others., Results: A total of 147,910 specialists were counted for a total population of 123,518,272 inhabitants; 69 % had current specialty certification. A rate of 119 specialists per 100 000 population was obtained; 54.2 % are in Mexico City and in the States of Mexico, Jalisco and Nuevo León. On average, there are 1.7 male specialists per female specialist., Conclusions: The number of specialists is lower than that internationally recommended and insufficient to cover the health needs of the country. Gender distribution is shifting towards a more equitable one. Specialists are mainly grouped in urban areas. This is the first census of specialists based on total verifiable number of physicians, which will allow the design of policies for human resources planning in health., (Copyright: © 2018 SecretarÍa de Salud.)

Background: Hip fractures are among the most serious bone fractures in the elderly, producing significant morbidity and mortality. Several observational studies have found that mild hyponatremia can adversely affect bone, with fractures occurring as a potential complication. We examined if there is an independent association between prolonged chronic hyponatremia (>90 days duration) and risk of hip fracture in the elderly., Methods: We performed a retrospective cohort study in adults >60 years of age from a prepaid health maintenance organization who had two or more measurements of plasma sodium between 2005 and 2012. The incidence of hip fractures was assessed in a very restrictive population: subjects with prolonged chronic hyponatremia, defined as plasma sodium values <135 mmol/L, lasting >90 days. Multivariable Cox regression was performed to determine the hazard ratio (HR) for hip fracture risk associated with prolonged chronic hyponatremia after adjustment for the propensity to have hyponatremia, fracture risk factors and relevant baseline characteristics., Results: Among 31 527 eligible patients, only 228 (0.9%) had prolonged chronic hyponatremia. Mean plasma sodium was 132 ± 5 mmol/L in hyponatremic patients and 139 ± 3 mmol/L in normonatremic patients (P < 0.001). The absolute risk for hip fracture was 7/282 in patients with prolonged chronic hyponatremia and 411/313 299 in normonatremic patients. Hyponatremic patients had a substantially elevated rate of hip fracture [adjusted HR 4.52 (95% CI 2.14-9.6)], which was even higher in those with moderate hyponatremia (<130 mmol/L) [adjusted HR 7.61 (95% CI 2.8-20.5)]., Conclusion: Mild prolonged chronic hyponatremia is independently associated with hip fracture risk in the elderly population, although the absolute risk is low. However, proof that correcting hyponatremia will result in a reduction of hip fractures is lacking., (© The Author 2016. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.)

Charcot arthropathy is defined as an articular degenerative, chronic, progressive disease that affects one or more peripheral joints, develops as a result of a failure in the normal sensory perception (pain and proprioception) in the innervation of joints located in the foot and ankle, is characterized by destructive bone lesions without the presence of infection. Neuropathy is directly associated with diabetes mellitus type 1 and 2. Surgery is indicated when there is severe involvement of soft tissue, foot joints are unstable, at the presence of chronic or recurrent ulcers or when the foot and ankle can not fit to a normal shoe, and had limitation to perform activities of daily living., Material and Methods: Charcot arthropathy is defined as an articular degenerative, chronic, progressive disease that affects one or more peripheral joints, develops as a result of a failure in the normal sensory perception (pain and proprioception) in the innervation of joints located in the foot and ankle, is characterized by destructive bone lesions without the presence of infection. Neuropathy is directly associated with diabetes mellitus type 1 and 2. Surgery is indicated when there is severe involvement of soft tissue, foot joints are unstable, at the presence of chronic or recurrent ulcers or when the foot and ankle can not fit to a normal shoe, and had limitation to perform activities of daily living., Design: observational, prospective, transversal, descriptive., Sample: patients diagnosed with Charcot neuropathy type 3a of Brodsky. Surgically treated by ankle arthrodesis with an intramedullary blocked nail, from January 2010 to August 2015., Results: 16 patients were analyzed. Preoperative AOFAS score was 35.0 ± 5.2 points. Postoperative follow-up period of 4 years to 7 months. Postoperative AOFAS scale showed an improvement of 40 points (p = 0.0001)., Conclusions: The proposed treatment allows bone stabilization, resulting in a full foot plantar support and decreases the occurrence of chronic ulcers that are difficult to treat, and is an alternative method that avoids lead to amputation.

In Argentina, education in clinical investigation is based on courses with theoric content. In developed countries programs with ongoing and practical content exist, generating the proper context to learn. In 2006, the Hospital Italiano de Buenos Aires (HIBA) created an area to train physicians, Research Area in Internal Medicine, and enable them to participate in every step of the clinical investigation process. The objective of this study is to describe this teaching area and its impact on the investigation in Internal Medicine in the HIBA, in the period 2006-2008. This area counts with fellow positions and provides training in Clinical Investigation for rotating residents. It has different activities including lectures, project counseling and 3 ongoing Institutional Registers for prevalent medical problems, 33% (6/18) of Intern staff are currently participating, with 3 fellows and 7 monitors for the Registers; 25 residents rotated in the area and generated their own research projects. 59 posters were presented in local and international congresses. Currently 6 original articles are in process of publication and 2 in peer review evaluation. A survey was carried out to evaluate the area where 76% (35/46) of the participants believed that they have acquired new skills; with 93% (44/47) using these knowledges in their every day practice. A 100% thought that they were adequately oriented in their projects, their ideas being fully respected (97%) (45/46). The inclusion of the Research Area in Internal Medicine improved the knowledge of the process of clinical Investigation and increased independent scientific production.