Surprising and novel multivariate sequential patterns using odds ratio for temporal evolution in healthcare.

BACKGROUND: Pattern mining techniques are helpful tools when extracting new knowledge in real practice, but the overwhelming number of patterns is still a limiting factor in the health-care domain. Current efforts concerning the definition of measures of interest for patterns are focused on reducing the number of patterns and quantifying their relevance (utility/usefulness). However, although the temporal dimension plays a key role in medical records, few efforts have been made to extract temporal knowledge about the patient's evolution from multivariate sequential patterns. METHODS: In this paper, we propose a method to extract a new type of patterns in the clinical domain called Jumping Diagnostic Odds Ratio Sequential Patterns (JDORSP). The aim of this method is to employ the odds ratio to identify a concise set of sequential patterns that represent a patient's state with a statistically significant protection factor (i.e., a pattern associated with patients that survive) and those extensions whose evolution suddenly changes the patient's clinical state, thus making the sequential patterns a statistically significant risk factor (i.e., a pattern associated with patients that do not survive), or vice versa. RESULTS: The results of our experiments highlight that our method reduces the number of sequential patterns obtained with state-of-the-art pattern reduction methods by over 95%. Only by achieving this drastic reduction can medical experts carry out a comprehensive clinical evaluation of the patterns that might be considered medical knowledge regarding the temporal evolution of the patients. We have evaluated the surprisingness and relevance of the sequential patterns with clinicians, and the most interesting fact is the high surprisingness of the extensions of the patterns that become a protection factor, that is, the patients that recover after several days of being at high risk of dying. CONCLUSIONS: Our proposed method with which to extract JDORSP generates a set of interpretable multivariate sequential patterns with new knowledge regarding the temporal evolution of the patients. The number of patterns is greatly reduced when compared to those generated by other methods and measures of interest. An additional advantage of this method is that it does not require any parameters or thresholds, and that the reduced number of patterns allows a manual evaluation.

Spatiotemporal Data Modelling for Epidemiological Research in Hospitals.

Nosocomial infections are a great source of concern for healthcare organizations. The spatial layout of hospitals and the movements of patients play significant roles in the spread of outbreaks. However, the existing models are ad-hoc for a specific hospital and research topic. This work shows the design of a data model to study the spread of infections among hospital patients. Its spatial dimension describes the hospital layout with several levels of detail, and the temporal dimension describes everything that happens to the patients in the form of events, which can relate to the spatial dimension. The model is meant to be sufficiently general to fit any hospital layout and to be used for different epidemiological research topics. We proved the model's suitability by defining six queries based on patients' movements and contacts that could assist in several epidemiological research tasks, such as discovering potential transmission routes. The model was implemented as an RDF* knowledge graph, and the queries were in SPARQL*. Finally, we designed two experiments in which two outbreaks of Clostridium difficile were analyzed using several queries (four in the first experiment and two in the second) on a knowledge graph (105,000 nodes, 185,000 edges) with synthetic data.

División ganglionar posquirúrgica y su efecto en el recuento ganglionar y la estadificación en pacientes con cáncer gástrico / Postoperative lymph node division and its effect on lymph node count and staging in patients with gastric cancer

Introducción. La gastrectomía y disección ganglionar es el estándar de manejo para los pacientes con cáncer gástrico. Factores como la identificación de ganglios por el patólogo, pueden tener un impacto negativo en la estadificación y el tratamiento. El objetivo de este estudio fue comparar el recuento ganglionar de un espécimen quirúrgico después de una gastrectomía completa (grupo A) y de un espécimen con un fraccionamiento por grupos ganglionares (grupo B). Métodos. Estudio de una base de datos retrospectiva de pacientes sometidos a gastrectomía D2 en el Servicio de Cirugía gastrointestinal de la Liga Contra el Cáncer seccional Risaralda, Pereira, Colombia. Se comparó el recuento ganglionar en especímenes quirúrgicos con y sin división ganglionar por regiones anatómicas previo a su envío a patología. Resultados. De los 94 pacientes intervenidos, 65 pertenecían al grupo A y 29 pacientes al grupo B. El promedio de ganglios fue de 24,4±8,6 y 32,4±14,4 respectivamente (p=0,004). El porcentaje de pacientes con más de 15 y de 25 ganglios fue menor en el grupo A que en el grupo B (27 vs 57, p=0,432 y 19 vs 24, p=0,014). El promedio de pacientes con una relación ganglionar menor 0,2 fue mayor en el grupo B (72,4 % vs 55,4 %, p=0,119). Conclusiones. Los resultados de nuestro estudio mostraron que una división por grupos ganglionares previo a la valoración del espécimen por el servicio de patología incrementa el recuento ganglionar y permite establecer de manera certera el pronóstico de los pacientes, teniendo un impacto positivo en su estadificación, para evitar el sobretratamiento

Introduction. A gastrectomy and lymph node dissection is the standard of management for patients with gastric cancer. Factors such as the identification of nodes by the pathologist can have a negative impact on staging and treatment. The objective of this study was to compare the lymph node count of a surgical specimen after a complete gastrectomy (group A) and of a specimen with lymph node by groups (group B). Methods. Study of a retrospective database of patients undergoing D2 gastrectomy in the Risaralda section of the Liga Contra el Cancer Gastrointestinal surgical service, Pereira, Colombia. The lymph node count was compared in surgical specimens with and without lymph node division by anatomical regions, prior to sending them to pathology. Results. Of the 94 patients who underwent surgery, 65 were from group A and 29 patients were from group B. The average number of nodes was 24.4±8.6 and 32.4±14.4, respectively (p=0.004). The percentage of patients with more than 15 and 25 nodes was lower in group A than in group B (27 vs 57, p=0.432 and 19 vs 24, p=0.014). The average number of patients with a nodal ratio less than 0.2 was higher in group B (72.4% vs 55.4%, p=0.119). Conclusions. The results of our study showed that a division by lymph node groups prior to the evaluation of the specimen by the pathology service increases the lymph node count and allows the prognosis of patients to be accurately established, having a positive impact on their staging, to avoid overtreatment.

Spatial-temporal simulation for hospital infection spread and outbreaks of Clostridioides difficile.

Validated and curated datasets are essential for studying the spread and control of infectious diseases in hospital settings, requiring clinical information on patients' evolution and their location. The literature shows that approaches based on Artificial Intelligence (AI) in the development of clinical-support systems have benefits that are increasingly recognized. However, there is a lack of available high-volume data, necessary for trusting such AI models. One effective method in this situation involves the simulation of realistic data. Existing simulators primarily focus on implementing compartmental epidemiological models and contact networks to validate epidemiological hypotheses. Nevertheless, other practical aspects such as the hospital building distribution, shifts or safety policies on infections has received minimal attention. In this paper, we propose a novel approach for a simulator of nosocomial infection spread, combining agent-based patient description, spatial-temporal constraints of the hospital settings, and microorganism behavior driven by epidemiological models. The predictive validity of the model was analyzed considering micro and macro-face validation, parameter calibration based on literature review, model alignment, and sensitive analysis with an expert. This simulation model is useful in monitoring infections and in the decision-making process in a hospital, by helping to detect spatial-temporal patterns and predict statistical data about the disease.

The use of networks in spatial and temporal computational models for outbreak spread in epidemiology: A systematic review.

OBJECTIVES: To examine recent literature in order to present a comprehensive overview of the current trends as regards the computational models used to represent the propagation of an infectious outbreak in a population, paying particular attention to those that represent network-based transmission. METHODS: a systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Papers published in English between 2010 and September 2021 were sought in the ACM Digital Library, IEEE Xplore, PubMed and Scopus databases. RESULTS: Upon considering their titles and abstracts, 832 papers were obtained, of which 192 were selected for a full content-body check. Of these, 112 studies were eventually deemed suitable for quantitative and qualitative analysis. Emphasis was placed on the spatial and temporal scales studied, the use of networks or graphs, and the granularity of the data used to evaluate the models. The models principally used to represent the spreading of outbreaks have been stochastic (55.36%), while the type of networks most frequently used are relationship networks (32.14%). The most common spatial dimension used is a region (19.64%) and the most used unit of time is a day (28.57%). Synthetic data as opposed to an external source were used in 51.79% of the papers. With regard to the granularity of the data sources, aggregated data such as censuses or transportation surveys are the most common. CONCLUSION: We identified a growing interest in the use of networks to represent disease transmission. We detected that research is focused on only certain combinations of the computational model, type of network (in both the expressive and the structural sense) and spatial scale, while the search for other interesting combinations has been left for the future.

Meaningful time-related aspects of alerts in Clinical Decision Support Systems. A unified framework.

Alerts are a common functionality of clinical decision support systems (CDSSs). Although they have proven to be useful in clinical practice, the alert burden can lead to alert fatigue and significantly reduce their usability and acceptance. Based on a literature review, we propose a unified framework consisting of a set of meaningful timestamps that allows the use of state-of-the-art measures for alert burden, such as alert dwell time, alert think time, and response time. In addition, it can be used to investigate other measures that could be relevant as regards dealing with this problem. Furthermore, we provide a case study concerning three different types of alerts to which the framework was successfully applied. We consider that our framework can easily be adapted to other CDSSs and that it could be useful for dealing with alert burden measurement thus contributing to its appropriate management.

Proteína C reactiva y su progresión en el tiempo para la detección de las fugas anastomóticas / C-reactive protein and its progression over time for the detection of anastomotic leaks

Introducción. Las fugas anastomóticas son una complicación común y crítica en cirugía gastrointestinal, por lo que su identificación y tratamiento temprano son necesarios para evitar resultados adversos. El uso convencional con un valor límite de la proteína C reactiva ha demostrado una utilidad limitada. El objetivo de este estudio fue determinar la utilidad de la medición seriada de la proteína C reactiva en la detección de fugas anastomóticas. Métodos. Revisión prospectiva de base de datos retrospectiva de pacientes sometidos a cirugía abdominal mayor con al menos una anastomosis intestinal. Se midió la proteína C reactiva al tercer y quinto día posoperatorio. Las complicaciones se categorizaron según la clasificación de Clavien-Dindo. La precisión diagnóstica fue evaluada por el área bajo la curva. Resultados. Se incluyeron 157 pacientes, el 52 % mujeres. La edad promedio fue de 63,7 años. El mayor número de cirugías correspondió a gastrectomía (36,3 %), resección anterior de recto (15,3 %) y hemicolectomía derecha (13,4 %). El 25,5 % tuvieron alguna complicación postoperatoria y el 32,5 % (n=13) presentaron fuga en la anastomosis. El aumento de la proteína C reactiva tuvo un área bajo la curva de 0,918 con un punto de corte de aumento en 1,3 mg/L, sensibilidad de 92,3 % (IC95% 78 ­ 100) y una especificidad de 92,4 % (IC95% 88 ­ 96). Conclusiones. El aumento de 1,3 mg/L en la proteína C reactiva entre el día de la cirugía y el quinto día fue un predictor preciso de fugas anastomóticas en pacientes con cirugía abdominal mayor

Introduction. Anastomotic leaks are a common and critical complication in gastrointestinal surgery. Their identification and early treatment are necessary to avoid adverse results, and conventional use with a cutoff value of C-reactive protein has shown limited utility. The objective of this study was to determine the usefulness of serial measurement of C-reactive protein in the detection of anastomotic leaks. Methods. Prospective review of a retrospective database of patients undergoing major abdominal surgery with at least one intestinal anastomosis. C-reactive protein was measured on the third and fifth postoperative days. Complications were classified according to the Clavien-Dindo classification. Diagnostic accuracy was evaluated by the area under the curve.Results. 157 patients were included, 52% were females. The average age was 63.7 years. The largest number of surgeries corresponded to gastrectomies (36.3%), anterior resection of the rectum (15.3%) and right hemicolectomies (13.4%). 25.5% had some postoperative complication and 32.5% (n=13) had anastomosis leaks. The increase in C-reactive protein had an area under the curve of 0.918 with an increase cut-off point of 1.3 mg/L, sensitivity of 92.3% (95% CI 78-100) and specificity of 92.4%. (95% CI 88-96). Conclusions. The 1.3 mg/L increase in C-reactive protein between the day of surgery and the fifth day was an accurate predictor of anastomotic leaks in patients with major abdominal surgery

Increase in C-reactive protein as early predictor of anastomotic leakage in abdominal surgery.

OBJECTIVES: The aim of this study was to evaluate the role of the C-reactive protein (CRP) and white cell count (WC) in the prediction of anastomotic leakage (AL) in major abdominal surgery. METHODS: Multicenter, prospective, and observational study of adult patients who underwent major abdominal surgery. CRP and hemogram were measured after post-operative day (POD) 3 and POD 5. Complications were classified according to the Clavien-Dindo classification. Diagnostic accuracy was evaluated by the area under the receiver operating characteristic curve (AUC). RESULTS: A total of 97 patients were included in the study. The mean age was 63 ± 12 years and 47 (48%) were male. Colorectal (56%) and gastric cancer (36%) were the most frequent diagnoses. About 23% had post-operative complications, of which 5% had AL. The most significant predictive factor was the increase in CRP ≥ 2.84 mg/L among POD 3 and 5 (AUC, 0.99, sensitivity, 95.6%, specificity, 100%, positive likelihood ratio, 23.0). The accuracy of the other biomarkers was lower, CRP on POD 3 (AUC, 0.55), on POD 5 (AUC, 0.93), WC on POD 3 (AUC, 0.33), and POD 5 (AUC, 0.35). CONCLUSION: The increase of CRP among POD 3 and 5 was an early predictor of AL in adult patients with major abdominal surgery.

OBJETIVO: El objetivo de este estudio fue evaluar el papel de la proteína C-reactiva (PCR) y el recuento de glóbulos blancos (RGB) en la predicción de la Fuga Anastomotica (FA) en la cirugía abdominal mayor. MÉTODO: Estudio multicéntrico, prospectivo y observacional de pacientes adultos sometidos a cirugía abdominal mayor. Se midieron la PCR y el hemograma después del día postoperatorio (DPO) 3 y DPO 5. Las complicaciones se categorizaron según la clasificación de Clavien-Dindo y la precisión diagnóstica se evaluó mediante el área bajo la curva (AUC). RESULTADOS: Se incluyeron un total de 97 pacientes. La edad media era de 63 ± 12 años y 47 (48%) eran hombres. El factor predictivo más significativo fue el aumento de la PCR ≥ 2,84 mg/L entre los DPO 3 y 5 (AUC, 0,99, sensibilidad, 95,6%, especificidad, 100%, ratio de probabilidad positiva, 23,0). La precisión de los demás biomarcadores fue menor, la PCR en el DPO 3 (AUC, 0,55), en el DPO5 (AUC, 0,93), el RGB en el DPO 3 (AUC, 0,33) y en el DPO 5 (AUC, 0,35). CONCLUSIONES: El aumento de la PCR entre los DPO 3 y 5 fue un predictor temprano de FA en pacientes adultos con cirugía abdominal mayor.

Descripción de la variación en el tiempo del cáncer gastrointestinal en el centro occidente de Colombia / Description of the variation in time of gastrointestinal cancer In Central-Western Colombia

Introducción. A nivel mundial los tumores gastrointestinales tienen un impacto importante en la mortalidad y se asocian a diferentes factores, entre ellos regionales y sociodemográficos. El objetivo de este estudio fue describir la variación en el tiempo del cáncer gastrointestinal en una población del centro occidente de Colombia, dada su alta incidencia y desenlace frecuentemente fatal.Métodos. Se realizó un estudio retrospectivo observacional con muestreo no probabilístico en un tiempo de seis años. Se seleccionaron pacientes diagnosticados con algún tipo de neoplasia del tracto digestivo, en un hospital de tercer nivel del centro occidente de Colombia. Resultados. Se evaluaron un total de 1152 pacientes. Los tumores del tracto digestivo superior (esófago, unión esófago-gástrica y estómago) fueron los más frecuentes (44 %), seguidos de los tumores del tracto digestivo medio e inferior (intestino delgado, colon, recto y ano; 31 %) y de los tumores hepato-bilio-pancreáticos (25 %). La edad media de presentación fue 64,6 años, con una mayor frecuencia en el sexo masculino (51,6 %). El adenocarcinoma fue el tipo histológico más común.Conclusión. Los resultados de este estudio muestran que los tumores gastrointestinales son una neoplasia frecuente en nuestro país, siendo los tumores gástricos los que se presentan con mayor prevalencia, seguidos de los tumores colorrectales y las neoplasias biliopancreáticas, las cuales se mantiene en el tiempo.

Introduction. Worldwide, gastrointestinal tumors have a significant impact on mortality and are associated with different factors, including regional and sociodemographics. The objective of this study was to describe the variation over time of gastrointestinal cancer in a population from Central-Western Colombia, given its high incidence and frequently fatal outcome. Methods. An observational retrospective study with non-probabilistic sampling was carried out over a period of six years. Patients diagnosed with some type of neoplasm of the digestive tract were selected in a tertiary care hospital in the Central-Western Colombia. Results. A total of 1152 patients were evaluated. Tumors of the upper digestive tract (esophagus, esophagogastric junction, and stomach) were the most frequent (44%), followed by tumors of the middle and lower digestive tract (small intestine, colon, rectum and anus; 31%), and hepatobiliary-pancreatic tumors (25%). The mean age of presentation was 64.6 years with a higher frequency in males (51.6%). Adenocarcinoma was the most common histological type.Conclusion. The results of this study show that gastrointestinal tumors are a frequent neoplasm in our country, with gastric tumors being the most prevalent, followed by colorectal tumors and biliopancreatic neoplasms, which are maintained over time.

Cáncer de vesícula biliar, una visión actual / Gallbladder cancer, a current view

Introducción. El diagnóstico de cáncer de vesícula biliar se realiza generalmente de forma incidental durante el estudio de las piezas quirúrgicas o cuando la enfermedad está avanzada y se expresa por su diseminación. Muy pocas veces se diagnostica de forma preoperatoria. Corresponde a la neoplasia más común de las vías biliares y su incidencia varía de acuerdo a la región geográfica. La región andina en Latinoamérica presenta una de las mayores incidencias a nivel mundial. Métodos. Se realizó una revisión narrativa de la literatura, para presentar una información actualizada en lo referente a los factores de riesgo (incluyendo las alteraciones genéticas y moleculares), al diagnóstico y al tratamiento de esta patología. Basados en los datos actuales, presentamos algunas recomendaciones dirigidas al diagnóstico temprano, que permita un manejo más adecuado de nuestros pacientes. Resultados. Se han implicado nuevos factores de riesgo relacionados con la etiología del cáncer de vesícula biliar, como la obesidad, factores genéticos y moleculares. A pesar de la disponibilidad de los métodos diagnósticos imagenológicos, no ha ocurrido una importante variación porcentual en cuanto al estadio al momento del diagnóstico. Conclusiones. El manejo quirúrgico del cáncer de vesícula biliar está indicado en los estadios más tempranos de la enfermedad y es importante evaluar las opciones terapéuticas en pacientes con enfermedad avanzada. Se considera de suma importancia el estudio anatomopatológico de la pieza quirúrgica y la revisión del informe por parte del cirujano.

Introduction. The diagnosis of gallbladder cancer is generally made incidentally during the study of the surgical pieces or when the disease is advanced and is expressed by its dissemination. It is rarely diagnosed preoperatively. It corresponds to the most common neoplasm of the bile ducts and its incidence varies according to the geographical region. The Andean region in Latin America presents one of the highest incidents worldwide. Methods. A narrative review of the literature was carried out to present updated information regarding risk factors (including genetic and molecular alterations), diagnosis and treatment of this pathology. Based on current data, we present some recommendations aimed at early diagnosis, which allows a more adequate management of our patients. Results. New risk factors related to the etiology of gallbladder cancer have been implicated, such as obesity, genetic and molecular factors. Despite the availability of diagnostic imaging methods, there has not been a significant percentage variation in terms of stage at diagnosis. Conclusions. Surgical management of gallbladder cancer is indicated in the earliest stages of the disease and it is important to evaluate therapeutic options in patients with advanced disease. The pathological study of the surgical piece and the review of the report by the surgeon are considered of utmost importance.

Hidradenitis suppurativa: Basic considerations for its approach: A narrative review.

Hidradenitis suppurativa is a chronic and debilitating skin disease, whose lesions can range from inflammatory nodules to abscesses and fistulas in the armpits, groin, perineum, inframammary region. Diagnosis can be confused with a large number of clinical pictures, and although studies on hidradenitis suppurativa are not so scarce in the literature, doctors are often unaware of this disease and therefore its diagnosis is often late. Pharmacological treatment ranges from retinoids to immunosuppression and radiation therapy, and surgical treatment ranges from incision and drainage to more complete excisions and laser therapies. Hidradenitis suppurativa is a disease seen and treated mainly by dermatologists and general surgeons, however, it is necessary for general practitioners to have basic knowledge about this entity, as they are the first line of care in the health system.

Lizard predation by spiders: A review from the Neotropical and Andean regions.

Vertebrate predation by invertebrates has been classically underexplored and thus underestimated, despite the fact that many arthropods consume vertebrates. To shed some light on the relevance that spider predation may have upon lizards in the Neotropical and Andean regions, we compiled the available information in the literature on this trophic interaction. We found 50 reports of spiders consuming lizards in these regions, and the 88% of these were from the Neotropical region. Spiders belong to eight families, but Ctenidae and Theraphosidae were the most frequently reported predators. Lizards belong to 12 families, and the most commonly consumed species corresponded to the families Dactyloidae (all Anolis lizards), Gymnophthalmidae, and Sphaerodactylidae. Data suggest trophic spider-lizard associations between Ctenidae and Dactyloidae, followed by Theraphosidae and Liolaemidae. The body sizes of the spiders and lizards showed a positive relationship, and spiders were smaller than their prey. We conclude that various spider taxa can be considered lizard predators and they may be ecologically important in the Neotropical and Andean regions. However, spiders of prime predation relevance seem to be those of the Ctenidae and Theraphosidae families.

Hybrid Esophagectomy: How I Do It?

The hybrid esophagectomy is a procedure that combines an initial laparoscopic approach in which the gastric conduit is prepared preserving the right gastroepiploic artery, followed by a right thoracotomy for resection of the esophagus, gastric pull-up into the chest, and esophagogastric anastomosis. Critical surgical steps should be carefully respected to perform a safe operation.

A methodology based on multiple criteria decision analysis for combining antibiotics in empirical therapy.

BACKGROUND: The current situation of critical progression in resistance to more effective antibiotics has forced the reuse of old highly toxic antibiotics and, for several reasons, the extension of the indications of combined antibiotic therapy as alternative options to broad spectrum empirical mono-therapy. A key aspect for selecting an appropriate and adequate antimicrobial therapy is that prescription must be based on local epidemiology and knowledge since many aspects, such as prevalence of microorganisms and effectiveness of antimicrobials, change from hospitals, or even areas and services within a single hospital. Therefore, the selection of combinations of antibiotics requires the application of a methodology that provides objectivity, completeness and reproducibility to the analysis of the detailed microbiological, epidemiological, pharmacological information on which to base a rational and reasoned choice. METHODS: We proposed a methodology for decision making that uses a multiple criteria decision analysis (MCDA) to support the clinician in the selection of an efficient combined empiric therapy. The MCDA includes a multi-objective constrained optimization model whose criteria are the maximum efficacy of therapy, maximum activity, the minimum activity overlapping, the minimum use of restricted antibiotics, the minimum toxicity of antibiotics and the activity against the most prevalent and virulent bacteria. The decision process can be defined in 4 steps: (1) selection of clinical situation of interest, (2) definition of local optimization criteria, (3) definition of constraints for reducing combinations, (4) manual sorting of solutions according to patient's clinical conditions, and (5) selection of a combination. EXPERIMENTS AND RESULTS: In order to show the application of the methodology to a clinical case, we carried out experiments with antibiotic susceptibility tests in blood samples taken during a five years period at a university hospital. The validation of the results consists of a manual review of the combinations and experiments carried out by an expert physician that has explained the most relevant solutions proposed according to current clinical knowledge and their use. CONCLUSION: We show that with the decision process proposed, the physician is able to select the best combined therapy according to different criteria such as maximum efficacy, activity and minimum toxicity. A method for the recommendation of combined antibiotic therapy developed on the basis of a multi-objective optimization model may assist the physicians in the search for alternatives to the use of broad-spectrum antibiotics or restricted antibiotics for empirical therapy. The decision proposed can be easily reproduced for any local epidemiology and any different clinical settings.

An International Collaborative Study on Surgical Education for Quality Improvement (ASSURED): A Project by the 2017 International Society of Surgery (ISS/SIC) Travel Scholars International Working Group.

BACKGROUND: There is a huge difference in the standard of surgical training in different countries around the world. The disparity is more obvious in the various models of surgical training in low- and middle-income countries (LMICs) compared to high-income countries. Although the global training model of surgeons is evolving from an apprenticeship model to a competency-based model with additional training using simulation, the training of surgeons in LMICs still lacks a standard pathway of training. METHODS: This is a qualitative, descriptive, and collaborative study conducted in six LMICs across Asia, Africa, and South America. The data were collected on the status of surgical education in these countries as per the guidelines designed for the ASSURED project along with plans for quality improvement in surgical education in these countries. RESULTS: The training model in these selected LMICs appears to be a hybrid of the standard models of surgical training. The training models were tailored to the country's need, but many fail to meet international standards. There are many areas identified that can be addressed in order to improve the quality of surgical education in these countries. CONCLUSIONS: Many areas need to be improved for a better quality of surgical training in LMICs. There is a need of financial, technical, and research support for the improvement in these models of surgical education in LMICs.

Impact of expert knowledge on the detection of patients at risk of antimicrobial therapy failure by clinical decision support systems.

Antimicrobial Susceptibility Tests (ASTs) are performed in hospitals to detect whether an infectious agent is resistant or susceptible to a set of antimicrobials. When AST results are available, the evaluation of the patient's antimicrobial therapy is a critical task to ensure its effectiveness against the found microorganism. Since not all the available antimicrobials can be tested in ASTs, clinicians rely on their expert knowledge to complement AST results and prescribe the most appropriate antimicrobials for each infection. Our goal is to help physicians in this task by improving the detection of antimicrobial therapies at risk of failure by Clinical Decision Support Systems (CDSSs). With this aim, we have incorporated the EUCAST expert rules in antimicrobial susceptibility testing into a CDSS to improve the results of ASTs. In order to achieve this, we have combined both ontologies and production rules. Furthermore, we have evaluated the impact of EUCAST expert rules on the detection of antimicrobial therapies at risk of failure. We performed a retrospective study with one year of clinical data, obtaining a total of 148 alerts from which 62 (41.9%) were based on the additional expert knowledge. Furthermore, the evaluation of the clinical relevance of 27 alerts resulted in 8 of them (29.7%) being clinically relevant. Of these, 6 were based on expert knowledge. Finally, an alarm fatigue study suggests that waiting between 48 and 72 h from the reception of the AST results can significantly reduce the number of alerts that are unnecessary in our CDSS because they are already being addressed in the hospital's daily workflow. In conclusion, we demonstrate that the incorporation of expert knowledge improves the capabilities of CDSSs as regards detecting the risk of antimicrobial therapy failure, which may improve the institutional outcomes in antimicrobial stewardship.

Primera experiencia de cirugía laparoscópica en cáncer del tracto digestivo superior / First experience of minimally invasive surgery in the upper digestive tract

Introducción: El cáncer del tracto digestivo superior es responsable de gran parte de las muertes a nivel mundial y es ampliamente asociada a los hábitos en el estilo de vida así como factores genéticos. Los abordajes mínimamente invasivos para su tratamiento son aun controversiales con curvas de aprendizaje empinadas, tiempos quirúrgicos prolongados pero con evidentes ventajas en sangrado, manejo del dolor, retorno a actividades y menores complicaciones relacionadas con la incisión. Objetivo: Describir nuestra primera experiencia en el tratamiento quirúrgico mínimamente invasivo en el Instituto Nacional de Cancerología del cáncer de tracto digestivo superior. Materiales y métodos: Revisión prospectiva de una base datos retrospectiva. Análisis descriptivo de pacientes en quienes se realizaron procedimientos mínimamente invasivos en el Instituto Nacional de Cancerología de Bogotá, Colombia, para el tratamiento del cáncer de tracto digestivo superior. Resultados: En 44 pacientes se realizo cirugía mínimamente invasiva para el tratamiento del cáncer del tracto digestivo superior. En 16 pacientes (36,4%) se realizó resección en cuña gástrica, en 13 pacientes (29,6%) gastrectomía total, en 9 pacientes (24,4%) gastrectomía subtotal y en 6 pacientes (13,6%) esofagectomía. No se presentaron complicaciones durante la cirugía, en 8 pacientes se presentaron complicaciones posoperatorias (18,2%). La estancia hospitalaria tuvo una mediana de 7,5 días. Conclusiones: La cirugía mínimamente invasiva para el tratamiento del cáncer del tracto digestivo superior en una técnica segura, factible, con tiempos quirúrgicos aceptables y sangrados mínimos en pacientes con y sin comorbilidades.

Background: Upper gastrointestinal cancer is responsible of important numbers deaths worldwide and is widely associated with lifestyle and genetic factors. Minimally invasive surgery treatment is still controversial wit difficult learning curves, longer operative times but clear advantages in bleeding, postoperative pain, return to activities and less complications associated with de incision. Objective: Describe our first experience in minimally invasive surgery of the upper alimentary tract for cancer at the Instituto Nacional de Cancerología. Materials and methods: Retrospective review of a prospectively set database. We describe the outcomes of patients in whom minimally invasive procedures, for the treatment of cancer of the upper alimentary tract was performed, at the InstitutoNacional de Cancerología in Bogotá, Colombia. Results: In 44 patients video assisted procedures were performed. In 16 of the 44 patients (36,4%) was wedged gastric resection, in 13 patients (29,6%) total gastrectomy, in 9 patients (24,4%) subtotal gastrectomy and in 6 patients (13,6%) and esophagectomy was performed. No intraoperative complications were present. Eight patients had any postoperative complication (18,2%). The average hospital stay was 7,5 days. Conclusions: Minimally invasive surgery for treatment of the upper gastrointestinal cancer is a safety and factible procedure with acceptable operative times and minimally bleeding in patients with or without co morbidities.

Eficacia diagnóstica de la impedancia basal nocturna media, un nuevo parámetro para el estudio de la enfermedad por reflujo gastroesofágico / Diagnostic efficacy of mean nocturnal basal impedance, a new parameter for the study of gastroesophageal reflux disease

Resumen Introducción y objetivos: el análisis de la impedancia basal nocturna media (IBNM) se ha propuesto para incrementar la precisión diagnóstica de enfermedad por reflujo erosiva (ERGE). Nuestro objetivo fue evaluar el rendimiento diagnóstico de esta prueba en un grupo de pacientes con ERGE conocida. Materiales y métodos: incluimos 123 individuos (58 con ERGE y 65 controles sanos) a quienes se les realizó pH-impedanciometría (pH-IMM) consecutiva entre enero de 2015 y junio de 2017. Todos los pacientes tenían endoscopia tomada en los 6 meses previos. El tiempo de exposición ácida (TEA) anormal (>4,2%) y la presencia de pirosis y/o regurgitación en los 6 meses previos fueron los criterios para el diagnóstico de ERGE. Se encontraron 58 pacientes con ERGE, 24 con enfermedad por reflujo erosiva (ERE) y 34 con enfermedad por reflujo no erosiva (ERNE). Los 65 restantes fueron controles sanos (CS) asintomáticos con EGD y pH-IMM normales. Todos los trazos de pH-IMM se reanalizaron para medir la IBNM por un segundo observador que desconocía los datos previos. El análisis estadístico incluyó pruebas múltiples de Bonferroni para comparar los grupos; regresión lineal para variables continuas; y análisis de curva ROC para buscar valor IBNM con mayor rendimiento. Para los diferentes parámetros de precisión diagnóstica se utilizó el punto de corte de la IBNM. Se usó significancia estadística con valor de p <0,01 e intervalos de confianza de 95% (IC 95%) para todos los cálculos. Resultados: los pacientes con ERE y ERNE presentaron valores de IBNM significativamente más bajos que el grupo control (p <0,01). Se observó una correlación negativa entre los valores de la IBNM y TEA (r = 0,59; p = <0,001), y también entre la IBNM y número de eventos de reflujo (r = 0,37; p = <0,001). En el análisis de curva ROC, el área bajo la curva de la IBNM fue de 0,941 (IC 95%: 0,894-0,987) y el punto de corte con mayor eficiencia 1102 ohms (sensibilidad 98,5%; especificidad 84,5%). Usando este valor (<1,102), la IBNM tuvo una sensibilidad para detectar ERGE de 91% (ERNE 86% y ERE 100%) y una especificidad de 98%. Conclusión: la IBNM tiene alta sensibilidad y especificidad para el diagnóstico de la ERGE. Adicionar esta prueba al análisis convencional de la pH-impedancia y a los métodos actuales de estudio de la ERGE puede mejorar significativamente nuestra capacidad para diagnosticar la enfermedad.

Abstract Introduction and Objectives: Analysis of nocturnal basal impedance (IBNM) has been proposed as a way to increase accuracy of GERD diagnosis. Our objective was to evaluate the diagnostic performance of this test in a group of patients known to have GERD. Materials and methods: We included 123 individuals: 58 with GERD and 65 healthy controls. They underwent consecutive pH-impedance monitoring between January 2015 and June 2017. All had undergone endoscopy in the 6 months prior to testing. Criteria used for diagnosis of GERD were abnormal acid exposure time (AET > 4.2%), pyrosis and/or regurgitation in the previous 6 months. We found 58 patients with GERD of whom 24 had erosive reflux disease (ERE) and 34 had non-erosive reflux disease (NERD). The remaining 65 were asymptomatic healthy controls with normal endoscopic results and pH impedance monitoring. A second observer who did not know the previous data measurements analyzed all pH impedance monitoring traces for IBMN. Statistical analysis included multiple Bonferroni tests for comparison between groups, linear regression for continuous variables, and receiver operating characteristic (ROC) curve analysis to find high performance IBNM values. The IBNM cutoff point was used for diagnostic precision parameters. Statistical significance was set at p <0.01, and 95% confidence intervals were used for all calculations. Results: IBNM measures were significantly lower for patients with ERE and NERD than for the control group (p <0.01). A negative correlation was observed between IBNM and acid exposure time values ​​(r = 0.59, p = <0.001) and also between IBNM and number of reflux events (r = 0.37, p = <0.001). ROC curve analysis found that the area under the curve for IBNM was 0.941 (95% CI: 0.894-0.987), and the cutoff point with the highest efficiency was 1,102 ohms (sensitivity 98.5%, specificity 84.5%). Using this value (<1.102), the IBNM had a sensitivity for detecting GERD of 91% (NERD 86% and ERE 100%) and a specificity of 98%. Conclusion: IBNM has high sensitivity and specificity for diagnosis of GERD. Addition of this test to conventional pH-impedance analysis and current methods for studying GERD can significantly improve our ability to diagnose this disease.

Tuberculosis abdominal: patología infrecuente en un paciente joven: reporte de un caso / Abdominal tuberculosis: an unusual disease in a young patient: a case report

Resumen Introducción: La tuberculosis abdominal es un problema reemergente, y es una de las enfermedades transmisibles más importante en todo el mundo. A pesar de las expectativas acerca de su erradicación en países en desarrollo, ha sido recientemente declarada de nuevo como una patología de emergencia mundial. Con el aumento de su incidencia y prevalencia, su forma abdominal es una de las presentaciones de afectación extrapulmonar más comunes. Objetivo: Dado que la tuberculosis puede afectar diversos órganos, tiene una amplia gama y gran espectro de signos y síntomas que dificultan su diagnóstico y retrasan el tratamiento. Por esto, se realiza esta revisión de tema, concentrándonos en que el alto índice de sospecha debe ser un factor importante en el diagnóstico precoz, para que una vez establecido, se pueda iniciar el tratamiento ayudando a prevenir y disminuir las altas tasas de morbilidad y mortalidad evidenciadas en la actualidad. Caso Clínico: Paciente joven con presencia de ascitis secundaria a tuberculosis abdominal confirmada por una biopsia y el aumento de la adenosin deaminasa en el líquido peritoneal. Se describen los principales hallazgos clínicos, paraclínicos, estudios imagenológicos y tratamiento.

Introduction: Abdominal tuberculosis is a reemerging problem and is one of the most important communicable diseases in the world. Despite expectations about the eradication in developing countries, it has recently been re-declared as a global emergency pathology. The increased incidence and prevalence shows an abdominal shape as one of the most common extrapulmonary involvement presentations. Objective: Since tuberculosis can affect various organs, it has a wide range and spectrum of signs and symptoms that make diagnosis difficult and delay treatment. Therefore, this review of the topic is done, concentrating on the fact that the high suspicion index should be an important factor in the early diagnosis. Treatment can be initiated helping to prevent and reduce high morbidity and mortality rates. Case Report: We present a case of a young patient with ascites secondary to abdominal tuberculosis confirmed by biopsy and increased adenosine deaminase in the peritoneal fluid. The main clinical findings, paraclinic, imaging studies and treatment are described.