Validación de una encuesta para medir la satisfacción de los médicos residentes sobre el programa de especialización en Lima, Perú / Validation of a survey aimed at measuring satisfaction of residents about a specialization program in Lima, Peru

RESUMEN Objetivo: Validar una encuesta para medir el nivel de satisfacción de los médicos residentes sobre el programa de segunda especialización en un hospital público de Lima, Perú. Material y métodos: Estudio transversal. El nuevo constructo se elaboró considerando los requisitos de satisfacción según opinión de los residentes y los 5 componentes de calidad de la encuesta SERVQUAL. Previo a su aplicación, fue sometida a opinión de expertos y prueba piloto para evaluar el grado de entendimiento de las preguntas y tiempo para su aplicación. La confiabilidad se evaluó con el alfa de Cronbach y la validez de constructo mediante análisis factorial. Realizamos estadística descriptiva y Chi cuadrado considerando significativo p<0,05. Resultados : Se analizaron 218 (82,0%) encuestas. 54,1% fueron del sexo femenino, 57,7% tenía edad ≤30 años, 86,2% era de plaza libre. El grado de entendimiento fue 9,98 y el tiempo de aplicación promedio fue 5,45 minutos. El alfa de Cronbach 0,919. Según el análisis factorial los 5 componentes principales de satisfacción explicaron el 65,5 % de la varianza de las 22 preguntas. La satisfacción global fue 71,8 %, fiabilidad 79,2%, capacidad de respuesta 80,2 %, seguridad 60,8%, empatía 82,8% y aspectos tangibles 55,9%. No se encontró diferencia significativa por género, grupo etario, modalidad de ingreso y especialidad. Conclusiones: La validación de la encuesta para medir satisfacción de los médicos residentes sobre el programa de segunda especialización demostró ser válida y confiable, constituyendo una herramienta útil para identificar las oportunidades de mejora para el perfeccionamiento continuo del programa de Residentado Médico.

SUMMARY Objective: To validate a survey aimed at measuring satisfaction of residents about a specialization program in Lima, Peru. Methods: A cross-sectional study was carried-out. The survey was built considering resident´s opinions on the satisfaction requirements of each program and the five components of the SERVQUAL quality survey. A pilot study was undertaken to evaluate the degree of understanding of the questions and an expert evaluation was also performed before applying the survey. Reliability was evaluated with Cronbach´s alpha test and validity was evaluated with a multifactorial analysis. Descriptive statistics was applied, Chi square test with a p value <0.05 was used. Results: 218 (82.0%) surveys were analyzed; 54.1% were females; 57.7% were younger than 30 years of age; 86.2% were of free position. Degree of understanding was 9.98 and time to complete the survey was 5.45 minutes. Cronbach´s alpha was 0.919. The factorial analysis of the five most important components of satisfaction explained 66.5% of the variance of the 22 questions. Overall satisfaction was 71.8%, reliability was 79.2%, ability to respond was 80.2%, security was 60.8%, empathy was 82.8% and tangible aspects was 55.9%. No difference by sex, age group, specialty and modality of admission was found. Conclusions: The survey tested showed to be reliable and valid to evaluate the satisfaction of residents to their programs and it is a useful tool to identify opportunities to improve the residency program.

Ketamina, un nuevo agente terapéutico para la depresión / Ketamine, a New Therapeutic Agent for Depression

Resumen: El trastorno depresivo mayor (TDM) afecta aproximadamente a una de cada 10 personas en México y es una de las primeras 5 causas de discapacidad a nivel global. Las opciones de tratamiento actuales son limitadas debido a que solo actúan en algunos de los factores fisiopatológicos relacionados con esta enfermedad, además de que los efectos sobre la depresión suelen ser retardados. Esto implica una importante limitación en disminuir la discapacidad que origina e impide una acción rápida ante la ideación suicida. Recientemente, la ketamina (un anestésico) ha probado tener propiedades antidepresivas a través de su actividad sobre el sistema de neurotransmisión glutamatérgica (ningún otro tratamiento actúa a este nivel). Logra mejoría de los síntomas depresivos en horas y ha resultado útil en pacientes que no responden a los tratamientos disponibles en la actualidad. Recientemente se aprobó su utilización para el tratamiento de este trastorno. Sin embargo, aún quedan interrogantes sobre sus mecanismos de acción antidepresiva, seguridad y efectos secundarios, entre otros.

Abstract: Major depressive disorder affects about one in every 10 people in Mexico and is one of the first 5 causes of disability worldwide. Current treatment options are limited and only act upon some factors associated in its physiopathology. Moreover, the effects on depression are not immediate, which is a great limitation in obtaining a benefit over disability caused by this disorder and impedes a rapid action in the scenario of suicidality. Recently, ketamine (an anesthetic) has shown to have antidepressant properties by acting in the glutamate neurotransmission system (while no other current treatment acts on this level). It offers benefits in depressive symptoms in a matter of hours and has proven to be useful in patients that do not benefit from current therapeutic options. Recently, it has been approved for the treatment of depression. However, there are still many questions about its antidepressant mechanisms of action, safety, side effects, among others.

Efecto sobre la talla en niñas con pubertad precoz central de diagnóstico tardío tratadas con análogos de GnRH / Effect of GnRH analogs on girls height with late diagnosis central precocious puberty

RESUMEN Objetivo: evaluar el efecto de los análogos de GnRH sobre la predicción de talla final adulta en niñas con pubertad precoz central de diagnóstico tardío. Materiales y métodos: estudio descriptivo, retrospectivo. Se incluyeron niñas atendidas entre 2012 y 2018 en la Unidad de Endocrinología Pediátrica del Hospital Cayetano Heredia con diagnóstico de pubertad precoz central idiopática de diagnóstico tardío. Se realizó evaluación antropométrica, evaluación de estadío Tanner y determinación de edad ósea con el método de Greulich y Pyle, estimando la predicción de talla final adulta mediante el método de Bayley Pinneau antes y después del tratamiento con análogos de GnRH. Se realizó t de student para comparar la predicción de talla antes y después del tratamiento. Se consideró significativo un p< 0,05. Resultados: se incluyeron 23 niñas con edad cronológica media de 8,4 ± 0,4 años y una edad ósea de 10,7 ± 0,8 años al ingreso. El 83,9% de las pacientes tuvieron exceso de peso y el 74,0% estadio Tanner 3 al diagnóstico. El tiempo promedio de tratamiento con análogos de GnRH fue de 20,5 ± 8,4 meses. El efecto del tratamiento calculado con la diferencia de predicción de talla final adulta menos predicción de talla inicial fue de 2,5 ± 4,1 cm (p<0,01). Conclusión: las niñas con diagnóstico de pubertad precoz central de diagnóstico tardío muestran un discreto beneficio sobre la predicción de talla final adulta, por lo que la terapia a esta edad debe ser individualizada.

ABSTRACT Objective: to assess the effect of GnRH analogues on predicted adult final height in girls with a late diagnosis of central precocious puberty. Material and Methods : this is a descriptive and retrospective study. Girls seen between 2012 and 2018 in the Pediatric Endocrinology Unit of Hospital Nacional Cayetano Heredia with a late diagnosis of idiopathic precocious central puberty were included. Anthropometric assessments were performed, Tanner stage assessment and bone age determination using the Greulich and Pyle method were performed, and the final adult height was predicted using the Bailey Pinneau method before and after therapy. A Student-t test was used for comparing the height prediction before and after therapy. A p<0.05 value was considered as significant. Results : twenty-three girls with mean chronological age 8.4 ± 0.4 years were included. Their bone age was 10.7 ± 0.8 on admission. Most of the patients (83.9%) were overweight and 74.3% were Tanner 3 at the time of diagnosis. The average time using GnRH analogues therapy was 20.5 ± 8.4 months. The effect of therapy, which was calculated using the prediction difference for the final adult height minus the initial height prediction was 2.5 ± 4.1 cm (p<0.001). Conclusion : girls with a diagnosis of late diagnosis central precocious puberty show a discrete benefit on the prediction of the final adult height, so therapy at this age should be individualized.

Utilidad del índice triglicéridos/HDL-C desde los primeros años de vida en el diagnóstico de síndrome metabólico en niños obesos / Utility of the triglycerides/HDL-C index from the first years of age in the diagnosis of metabolic syndrome in obese children

Objetivo: Determinar la utilidad del índice triglicéridos/HDL-C (TG/HDL-C) para el diagnóstico de síndrome metabólico (SM) en niños obesos de 2 a 14 años. Material y métodos: Estudio transversal tipo prueba de diagnóstico. Fueron incluidos 360 niños obesos exógenos (199M/161F), divididos en tres grupos etarios: 2 a <6 años, 6 a <10 años y 10 a 14 años. Se definió SM según los criterios de la International Diabetes Federation y se evaluó al índice TG/HDL-C como diagnóstico en dos puntos de corte: ≥2,32 y ≥3,5, en cada grupo etario. Se aplicó Chi cuadrado, considerándose significativo p<0,05. Se determinó la sensibilidad, especificidad y valores predictivos positivo y negativo, para cada punto de corte. Resultados: La frecuencia de SM fue 15,79% de 2 a <6 años, 20,25% de 6 a <10 años, 19,63% de 10 a 14 años. En los niños con SM el 97,1% presentó HDL bajo, 83,8% triglicéridos elevados. Se encontró diferencia significativa en la frecuencia del índice TG/HDL-C en ambos puntos de corte, entre los niños con y sin SM en todos los grupos etarios. La sensibilidad para ambos puntos de corte fue alta (86-100%) y la especificidad fue mejor para el punto de corte ≥3,5 (72-80%). Conclusiones: El índice TG/HDL-C ≥3,5 representaría un marcador sensible y específico para el diagnóstico de síndrome metabólico desde los primeros años de vida.

Objective: To determine the utility of the triglycerides/HDL-C index for the diagnosis of metabolic syndrome (MS) in obese 2-14 years of age children. Methods: Cross-sectional diagnostic study. We included 360 exogenous obese children (199M/161F) divided in three age groups: 2 to <6; 6 to <10 and 10-14 years. MS was defined according to the International Diabetes Federation and the TG/HDL-C index was evaluated using two cutoffs by age group, ≥2.32 and ≥3.5. Chi squared was used accepting a p value <0.05 as statistically significant. Fir each cut-off we determined sensitivity, specificity and predictive values. Results: Frequency of MS was 15.79% in the 2 to <6 years age group; 20.25% in the 6 to<10 years age group and 19.63% in the 10-14 years age group. Among children with SM, 97.1% had low HDL and 83.8% had elevated triglycerides. A statistically significant difference was found in the frequency of the TG/HDL-C index in children with or without MS in all age groups. Sensitivity for all cut-offs was high (86-100%) and specificity was best for the cut-off of ≥3.5 (72-80%). Conclusions: The TG/HDL-C index is a sensitive and specific marker of MS from the first years of age.

Alanina aminotransferasa como marcador en el diagnóstico de síndrome metabólico y riesgo cardiovascular en niños con obesidad / Alanine aminotransferase as a marker for diagnosing metabolic syndrome and cardiovascular risk in obese children

Objetivo: Evaluar la alanina aminotransferasa (ALT) como marcador en el diagnóstico de síndrome metabólico (SM) y riesgo cardiovascular (RCV) en niños con obesidad exógena. Materiales y métodos: Estudio transversal. Se incluyeron niños con obesidad exógena de 2 a 14 años, atendidos en la Unidad de Endocrinología Pediátrica del Hospital Nacional Cayetano Heredia, entre el 2014 al 2018. Se definió enfermedad hepática no alcohólica (EHNA) considerando dos puntos de corte de ALT; en mujeres: >22,1U/L y >44U/L, en varones: >25,8U/L y >50U/L. Se definió SM según la Academia Americana de Pediatría y RCV con TG/HDL-C ≥3,5. Aplicamos Chi cuadrado, considerándose significativo p<0,05. Estimamos sensibilidad(S), especificidad (E) y likelihood ratios (LR). Resultados: Se incluyeron 347 niños obesos (54,7% varones). La frecuencia de EHNA fue de 23,1%. La sensibilidad y especificidad para el diagnóstico de SM con ALT >22,1U/L y >25,8U/L fue 79,4% y 37,6% respectivamente y, con ALT>44U/L y >50U/L fue 28,6% y 83,3%. La ALT con punto de corte mayor en conjunto con TG/HDL-C≥3,5 mostró una especificidad del 96,9% y un likelihood ratio + (LR+) de 6,7. Conclusión: La ALT con un punto de corte >44U/L en mujeres y >50U/L en varones, es un marcador bioquímico útil en la identificación de SM y riesgo cardiovascular en niños con obesidad exógena desde los primeros años de vida.

Objective: To assess alanine aminotransferase (ALT) as a marker for diagnosing metabolic syndrome (MS) and cardiovascular risk in children with exogenous obesity. Materials and Methods: This is a cross-sectional study. Children with exogenous obesity between 2 and 14 years of age seen in the Pediatric Endocrinology Unit at Cayetano Heredia Hospital between 2014 and 2018 were included. Non alcoholic liver disease was defined considering two ALT cutoff points: >22.1 U/L and >44 U/L in females and >25.8 U/L and >50 U/L in males. MS was defined according to the American Academy of Pediatrics criteria, and cardiovascular risk was defined with TG/HDL-C ratio ³3.5. We used chi-square test, and p<0.05 was deemed as significant. We estimated sensitivity (S), specificity (E) and likelihood ratios (LR). Results: Three-hundred and forty-seven obese children were included (54.7% were male). Non-alcoholic liver disease frequency was 23.1%. Sensitivity and specificity values for diagnosing MS with ALT >22.1 U/L and >25.8 U/L were 79.4% and 37.6%, respectively; and with ALT >44 U/L and 50 U/L these values were 28.6% and 83.3%. ALT levels with higher cutoff values, together with a ³3.5 TG/HDL-C ratio showed 96.9% specificity and 6.7 likelihood ratio (LR+). Conclusion: ALT levels with a >44 U/L cutoff value in females and >50 U/L in males is a useful biochemical marker for identifying MS and determining cardiovascular risk in children with exogen obesity during their early years of life.

Past and present land use influences on tropical riparian zones: an isotopic assessment with implications for riparian forest width determination / Influências pretéritas e presentes do uso da terra sobre zonas ripárias tropicais: uma avaliação isotópica com implicações para a determinação da largura de florestas ripárias

Abstract In this article, by using carbon stable isotopes, we assessed the past and present land use influences that riparian areas are subject within agricultural landscapes. Emphasis is given to the understanding of the effects of the 2012 Brazilian Forest Act on such areas. We selected five riparian areas within a highly C4 dominated agricultural landscape. Three of them had 30 meters native riparian forest buffer (NRFB) and two of them had 8 meter and no NRFB. We used three 100 meter-transects located 5, 15 and 30 meters relative to stream channel to obtain soil samples (0 - 10 cm). All riparian areas presented soil carbon isotopic signatures that are not C3 (native forests) irrespective of having or not 30 meters NRFB. Two cases presenting less than 30 meters NRFB had higher C4 derived carbon contribution. All of the other three areas that followed the 30 meters NRFB presented, to some degree, C4 derived carbon, which was attributed to C4 organic matter deposition originated from cultivated areas and, in one case, to the persistence of former exotic grasses. With the 2012 Forest Act allowing narrower buffers (< 30 meters), we expect C4 contributions to soil organic matter to remain high in riparian areas and streams within agricultural landscapes dominated by C4 plants where 30 meter NRFB is no longer required. Such contributions will likely continue to have detrimental effects on stream water quality and biota.

Resumo Neste artigo, ao utilizar isótopos estáveis de carbono, nós avaliamos as influências presentes e pretéritas do uso da terra a que as áreas ripárias estão sujeitas quando situadas dentro de paisagens agrícolas. Ênfase é dada ao entendimento dos efeitos do Código Florestal de 2012 em tais áreas. Nós selecionamos cinco áreas ripárias em uma paisagem agrícola altamente dominada por plantas C4. Três delas apresentam faixa ripária de floresta nativa (FRFN) de 30 metros de largura e as outras duas apresentam FRFN de 8 e 0 m (i.e. sem FRFN). Nós utilizamos três transectos de 100 metros localizados a 5, 15 e 30 metros de distância do canal fluvial para obter amostras de solo (0 - 10 cm). Todas as áreas ripárias apresentaram assinaturas isotópicas do carbono do solo que não são C3 (floresta nativa) independentemente de apresentarem ou não FRFN de 30 metros. Os dois casos em que FRFN era menor que 30 m apresentaram maior contribuição de carbono oriundo de plantas C4. Todas as outras três áreas com FRFN de 30 m também apresentaram, em algum grau, carbono oriundo de plantas C4. Todas as outras três áreas com FRFN de 30 m também apresentaram, em algum grau, carbono oriundo de plantas C4 que foi atribuído è deposição de matéria orgânica de plantas C4 originada das áreas cultivadas e, em um caso, è persistência de gramíneas exóticas pré-existentes. Com o Código Florestal de 2012 permitindo FRFN mais estreitas (< 30 metros), nós esperamos que a contribuição de plantas C4 para a matéria orgânica permaneça alta em áreas ripárias e rios dentro de paisagens agrícolas dominadas por plantas C4 onde a FRFN de 30 m não é mais uma obrigação. Tais contribuições irão, provavelmente, continuar a ter efeitos prejudiciais è qualidade de água dos rios e à sua biota.

Does the rattle of Crotalus durissus terrificus reveal its dietary history?

Background Environmental devastation threatens the survival of many species, including venomous snakes such as the South American rattlesnake Crotalus durissus terrificus. This observation is based on the decrease of snakes collected and donated to Brazilian research institutes. Nevertheless, some individuals have managed to survive and procreate. The question is how these snakes are adapting in these new environmental conditions.Methods To answer it, the carbon-13 level of rattlesnakes and their feed (either laboratory or wild mice) was evaluated by isotope-ratio mass spectrometry. Thus, rattle segments from 16 adults and 15 offspring of captive snakes, and of three wild newborn C. d. terrificus were evaluated as well as 17 Mus musculus mice captured in traps, four live feeder mice and the ration offered to mice at animal houses.Results The isotopic exchange time of the captive adult snakes (n = 16) varied between 33 and 37 months and of captive-born animals (n = 15), until reaching a plateau of equilibrium, varied from 18 to 24 months. Regarding the captured Mus musculus (n = 17), 88.23% (n = 15) were from a C4 environment. Of the six rattle rings from offspring of captured C. d. terrificus, five were from a C4environment, whereas of the 170 rattle rings studied, 60% originated from a C3 environment and 40% from a C4. The same carbon-13 values were found in captive snakes.Conclusions Based on the present results, it can be inferred that most C. d. terrificus snakes (60%) fed animals from a C3environment; birds consist of an alimentary alternative for snakes, as well as rodents, small reptiles and amphibians; different venom compositions among snakes from the same region may be related to the food type; the primary rattle of offspring reflects the maternal diet during gestation; and, finally, the different rattle rings indicate the alimentary history of these animals.(AU)

Does the rattle of Crotalus durissus terrificus reveal its dietary history?

Background Environmental devastation threatens the survival of many species, including venomous snakes such as the South American rattlesnake Crotalus durissus terrificus. This observation is based on the decrease of snakes collected and donated to Brazilian research institutes. Nevertheless, some individuals have managed to survive and procreate. The question is how these snakes are adapting in these new environmental conditions.Methods To answer it, the carbon-13 level of rattlesnakes and their feed (either laboratory or wild mice) was evaluated by isotope-ratio mass spectrometry. Thus, rattle segments from 16 adults and 15 offspring of captive snakes, and of three wild newborn C. d. terrificus were evaluated as well as 17 Mus musculus mice captured in traps, four live feeder mice and the ration offered to mice at animal houses.Results The isotopic exchange time of the captive adult snakes (n = 16) varied between 33 and 37 months and of captive-born animals (n = 15), until reaching a plateau of equilibrium, varied from 18 to 24 months. Regarding the captured Mus musculus (n = 17), 88.23% (n = 15) were from a C4 environment. Of the six rattle rings from offspring of captured C. d. terrificus, five were from a C4environment, whereas of the 170 rattle rings studied, 60% originated from a C3 environment and 40% from a C4. The same carbon-13 values were found in captive snakes.Conclusions Based on the present results, it can be inferred that most C. d. terrificus snakes (60%) fed animals from a C3environment; birds consist of an alimentary alternative for snakes, as well as rodents, small reptiles and amphibians; different venom compositions among snakes from the same region may be related to the food type; the primary rattle of offspring reflects the maternal diet during gestation; and, finally, the different rattle rings indicate the alimentary history of these animals.