Risk factors for respiratory failure among hospitalized patients with Guillain–Barré syndrome / Factores de riesgo de insuficiencia respiratoria en pacientes hospitalizados con síndrome de Guillain-Barré

Background Guillain–Barré syndrome (GBS) is an acute inflammatory polyneuropathy that can lead to respiratory failure. In this study, we evaluate early clinical risk factors for respiratory failure at the time of hospital admission.Methods We studied a retrospective cohort of patients with GBS admitted to a tertiary care center. The potential risk factors studied were sociodemographic characteristics, GBS symptoms, overall and cervical muscle weakness (Medical Research Council [MRC] scores), electromyography findings, and cerebrospinal fluid analysis findings. Unadjusted odds ratios (OR) were calculated and exact logistic regression analysis (adjusted OR) performed to assess the association between baseline risk factors and respiratory failure. Results Overall, 13 of 113 (12%) patients included in the study developed respiratory failure. Unadjusted analyses showed that involvement of any cranial nerve (OR: 14.7; 95% CI, 1.8–117.1), facial palsy (OR: 17.3; 95% CI, 2.2–138.0), and bulbar weakness (OR: 10.7; 95% CI, 2.3–50.0) were associated with increased risk of respiratory failure. Lower MRC sum scores (for scores <30, OR: 14.0; 95% CI, 1.54–127.2) and neck MRC scores (for scores ≤3, OR: 21.0; 95% CI, 3.5–125.2) were associated with higher likelihood of respiratory failure. Adjusted analyses showed that presence of bulbar weakness (OR: 7.6; 95% CI, 1.3–43.0) and low neck MRC scores (scores ≤3, OR: 9.2; 95% CI, 3.5–125.2, vs scores >3) were independently associated with respiratory failure. Conclusions Bulbar and neck muscle weakness at admission are clinical predictors of increased risk of respiratory failure in patients with GBS. These findings could guide the adequate management of high-risk patients. (AU)

Introducción El síndrome de Guillain-Barré es una polineuropatía inflamatoria aguda que puede causar insuficiencia respiratoria. Evaluamos los factores de riesgo clínicos en el momento de la hospitalización. Métodos Realizamos un estudio de una cohorte retrospectiva de pacientes con síndrome de Guillain-Barré hospitalizados en un centro de tercer nivel. Analizamos las características sociodemográficas, síntomas de la enfermedad, fuerza muscular general y cervical (escala del Medical Research Council [MRC]), hallazgos electromiográficos, y resultados del análisis del líquido cefalorraquídeo. Calculamos el odds ratio (OR) sin ajustar y realizamos una regresión logística exacta (OR ajustada) para evaluar la asociación entre los factores de riesgo y la insuficiencia respiratoria. Resultados Trece de los 113 pacientes incluidos (12%) presentó insuficiencia respiratoria. Los análisis no ajustados mostraron una asociación entre mayor riesgo de insuficiencia respiratoria y la afectación de cualquier par craneal (OR: 14,7; IC 95%, 1,8-117,1), parálisis facial (OR: 17,3; IC 95%, 2,2-138,0) y debilidad bulbar (OR: 10,7; IC 95%, 2,3-50,0). Unas puntuaciones más bajas en la MRC-total (puntuaciones <30, OR: 14,0; IC 95%, 1,54-127,2) y en la MRC-cervical (puntuaciones <3, OR: 21,0; IC 95%, 3,5-125,2) se asociaron con una mayor probabilidad de presentar insuficiencia respiratoria. En los análisis ajustados, la presencia de debilidad bulbar (OR: 7,6; IC 95%, 1,3-43,0) y una puntuación baja en la MRC-cervical (puntuaciones ≤3, OR: 9,2; IC 95%, 3,5-125,2, frente a puntuaciones >3) se asociaron de forma independiente con la insuficiencia respiratoria. Conclusiones La presencia de debilidad bulbar y cervical en el momento de la hospitalización es un factor de riesgo de insuficiencia respiratoria en pacientes con síndrome de Guillain-Barré. Estos hallazgos pueden servir de guía para el manejo de los pacientes con mayor riesgo de presentar dicha complicación. (AU)

Risk factors for respiratory failure among hospitalized patients with Guillain–Barré syndrome / Factores de riesgo de insuficiencia respiratoria en pacientes hospitalizados con síndrome de Guillain-Barré

Background Guillain–Barré syndrome (GBS) is an acute inflammatory polyneuropathy that can lead to respiratory failure. In this study, we evaluate early clinical risk factors for respiratory failure at the time of hospital admission.Methods We studied a retrospective cohort of patients with GBS admitted to a tertiary care center. The potential risk factors studied were sociodemographic characteristics, GBS symptoms, overall and cervical muscle weakness (Medical Research Council [MRC] scores), electromyography findings, and cerebrospinal fluid analysis findings. Unadjusted odds ratios (OR) were calculated and exact logistic regression analysis (adjusted OR) performed to assess the association between baseline risk factors and respiratory failure. Results Overall, 13 of 113 (12%) patients included in the study developed respiratory failure. Unadjusted analyses showed that involvement of any cranial nerve (OR: 14.7; 95% CI, 1.8–117.1), facial palsy (OR: 17.3; 95% CI, 2.2–138.0), and bulbar weakness (OR: 10.7; 95% CI, 2.3–50.0) were associated with increased risk of respiratory failure. Lower MRC sum scores (for scores <30, OR: 14.0; 95% CI, 1.54–127.2) and neck MRC scores (for scores ≤3, OR: 21.0; 95% CI, 3.5–125.2) were associated with higher likelihood of respiratory failure. Adjusted analyses showed that presence of bulbar weakness (OR: 7.6; 95% CI, 1.3–43.0) and low neck MRC scores (scores ≤3, OR: 9.2; 95% CI, 3.5–125.2, vs scores >3) were independently associated with respiratory failure. Conclusions Bulbar and neck muscle weakness at admission are clinical predictors of increased risk of respiratory failure in patients with GBS. These findings could guide the adequate management of high-risk patients. (AU)

Introducción El síndrome de Guillain-Barré es una polineuropatía inflamatoria aguda que puede causar insuficiencia respiratoria. Evaluamos los factores de riesgo clínicos en el momento de la hospitalización. Métodos Realizamos un estudio de una cohorte retrospectiva de pacientes con síndrome de Guillain-Barré hospitalizados en un centro de tercer nivel. Analizamos las características sociodemográficas, síntomas de la enfermedad, fuerza muscular general y cervical (escala del Medical Research Council [MRC]), hallazgos electromiográficos, y resultados del análisis del líquido cefalorraquídeo. Calculamos el odds ratio (OR) sin ajustar y realizamos una regresión logística exacta (OR ajustada) para evaluar la asociación entre los factores de riesgo y la insuficiencia respiratoria. Resultados Trece de los 113 pacientes incluidos (12%) presentó insuficiencia respiratoria. Los análisis no ajustados mostraron una asociación entre mayor riesgo de insuficiencia respiratoria y la afectación de cualquier par craneal (OR: 14,7; IC 95%, 1,8-117,1), parálisis facial (OR: 17,3; IC 95%, 2,2-138,0) y debilidad bulbar (OR: 10,7; IC 95%, 2,3-50,0). Unas puntuaciones más bajas en la MRC-total (puntuaciones <30, OR: 14,0; IC 95%, 1,54-127,2) y en la MRC-cervical (puntuaciones <3, OR: 21,0; IC 95%, 3,5-125,2) se asociaron con una mayor probabilidad de presentar insuficiencia respiratoria. En los análisis ajustados, la presencia de debilidad bulbar (OR: 7,6; IC 95%, 1,3-43,0) y una puntuación baja en la MRC-cervical (puntuaciones ≤3, OR: 9,2; IC 95%, 3,5-125,2, frente a puntuaciones >3) se asociaron de forma independiente con la insuficiencia respiratoria. Conclusiones La presencia de debilidad bulbar y cervical en el momento de la hospitalización es un factor de riesgo de insuficiencia respiratoria en pacientes con síndrome de Guillain-Barré. Estos hallazgos pueden servir de guía para el manejo de los pacientes con mayor riesgo de presentar dicha complicación. (AU)

Risk factors for respiratory failure among hospitalized patients with Guillain-Barré syndrome.

BACKGROUND: Guillain-Barré syndrome (GBS) is an acute inflammatory polyneuropathy that can lead to respiratory failure. In this study, we evaluate early clinical risk factors for respiratory failure at the time of hospital admission. METHODS: We studied a retrospective cohort of patients with GBS admitted to a tertiary care center. The potential risk factors studied were sociodemographic characteristics, GBS symptoms, overall and cervical muscle weakness (Medical Research Council [MRC] scores), electromyography findings, and cerebrospinal fluid analysis findings. Unadjusted odds ratios (OR) were calculated and exact logistic regression analysis (adjusted OR) performed to assess the association between baseline risk factors and respiratory failure. RESULTS: Overall, 13 of 113 (12%) patients included in the study developed respiratory failure. Unadjusted analyses showed that involvement of any cranial nerve (OR: 14.7; 95% CI, 1.8-117.1), facial palsy (OR: 17.3; 95% CI, 2.2-138.0), and bulbar weakness (OR: 10.7; 95% CI, 2.3-50.0) were associated with increased risk of respiratory failure. Lower MRC sum scores (for scores <30, OR: 14.0; 95% CI, 1.54-127.2) and neck MRC scores (for scores ≤3, OR: 21.0; 95% CI, 3.5-125.2) were associated with higher likelihood of respiratory failure. Adjusted analyses showed that presence of bulbar weakness (OR: 7.6; 95% CI, 1.3-43.0) and low neck MRC scores (scores ≤3, OR: 9.2; 95% CI, 3.5-125.2, vs scores >3) were independently associated with respiratory failure. CONCLUSIONS: Bulbar and neck muscle weakness at admission are clinical predictors of increased risk of respiratory failure in patients with GBS. These findings could guide the adequate management of high-risk patients.

Risk factors for respiratory failure among hospitalized patients with Guillain-Barré syndrome.

BACKGROUND: Guillain-Barré syndrome (GBS) is an acute inflammatory polyneuropathy that can lead to respiratory failure. In this study, we evaluate early clinical risk factors for respiratory failure at the time of hospital admission. METHODS: We studied a retrospective cohort of patients with GBS admitted to a tertiary care center. The potential risk factors studied were sociodemographic characteristics, GBS symptoms, overall and cervical muscle weakness (Medical Research Council [MRC] scores), electromyography findings, and cerebrospinal fluid analysis findings. Unadjusted odds ratios (OR) were calculated and exact logistic regression analysis (adjusted OR) performed to assess the association between baseline risk factors and respiratory failure. RESULTS: Overall, 13 of 113 (12%) patients included in the study developed respiratory failure. Unadjusted analyses showed that involvement of any cranial nerve (OR: 14.7; 95% CI, 1.8-117.1), facial palsy (OR: 17.3; 95% CI, 2.2-138.0), and bulbar weakness (OR: 10.7; 95% CI, 2.3-50.0) were associated with increased risk of respiratory failure. Lower MRC sum scores (for scores <30, OR: 14.0; 95% CI, 1.54-127.2) and neck MRC scores (for scores ≤3, OR: 21.0; 95% CI, 3.5-125.2) were associated with higher likelihood of respiratory failure. Adjusted analyses showed that presence of bulbar weakness (OR: 7.6; 95% CI, 1.3-43.0) and low neck MRC scores (scores ≤3, OR: 9.2; 95% CI, 3.5-125.2, vs scores >3) were independently associated with respiratory failure. CONCLUSIONS: Bulbar and neck muscle weakness at admission are clinical predictors of increased risk of respiratory failure in patients with GBS. These findings could guide the adequate management of high-risk patients.

Kernohan-Woltman notch phenomenon: Beware of the wrong side / Fenómeno de Kernohan-Woltman: ¡cuidado con el lado equivocado

No disponible

Duropleural fistula revealed by neurological manifestations: an unusual cause of pleural effusion.

Symptomatic pleural collection of cerebrospinal fluid is a rare but accepted complication in hydrocephalic paediatric patients treated with ventriculopleural shunts. Few cases have been described in adults, usually as complication of trauma, tumours or spinal surgery, particularly post-laminectomy. It should be considered in the differential diagnosis of pleural effusion after neurosurgical procedures involving the spine. We describe two patients with large cerebrospinal fluid collections in the pleural cavity caused by postoperative duropleural fistula, who presented with neurological symptoms, cerebrospinal fluid pressure headache and meningitis.

Neumonía grave por Pneumocystis jirovecii en pacientes no HIV con enfermedades neoplásicas / Severe Pneumocystis jirovecci pneumonia in HIV-negative patients with neoplastic diseases

La neumonía por Pneumocystis jirovecii es una infección oportunista frecuente en pacientes positivos al VIH y CD4 < 200 células/mm3. Sin embargo, también se observa en pacientes inmunocomprometidos secundaria al tratamiento con inmunosupresores y altas dosis de esteroides. En estos pacientes, la neumonía grave de la comunidad o la neutropenia febril con infiltrados pulmonares difusos son las presentaciones clínicas más habituales; ambos cuadros cursan generalmente con hipoxemia severa. La falla respiratoria aguda con requerimientos de ventilación mecánica y alto riesgo de muerte intrahospitalaria ocurre con más frecuencia que en los pacientes positivos al VIH. El diagnóstico se realiza con tinción de Grocot, inmunofluorescencia indirecta (lFI) o PCR en lavado broncoalveolar. El tratamiento antibiótico debe incluir trimetoprim-sulfametozaxol y corticoides como adyuvantes. Es frecuente la coinfección con otros patógenos oportunistas, como citomegalovirus o Cándida albicans. Presentamos 4 pacientes VIH negativos, inmunosuprimidos por el tratamiento para enfermedades neoplásicas con neumonía grave por Pneumocystis jirovecii, dos de ellos en el contexto de neutropenia febril y tres con probable co-infección por ctfomegalovirus.

Pneumocystis jirovecii's pneumonia (PCP) is a well known and frequent opportunistic infection in HIV patients with a CD4 cell count under 200 cells/mm3. However, it can be seen in other inmunosupressed patients, secondary to the use of chemotherapy and high dose of steroids. The most common clinical manifestation are severe community-acquired pneumonia and fever with neutropenia plus diffuse lung infiltrates; generally severe hypoxemia is associated with both clinical manifestations. Acute respiratory failure requiring mechanical ventilation and a high risk of death at hospital are more frequent in HIV-negative than in HIV-positive patients. Diagnosis is achieved with Grocot stain, indirect immunofluorescence (IIF) or PCR, in bronchoalveolar lavage samples. Initial treatment should include cotrimoxazole, with adjuvant steroids. Coinfections with other opportunistic pathogens such a Cytomegalovirus or candlda albicans are frequent. The report describes 4 cases of Pneumocystis jirovecii pneumonia, in HIV negative patients, who are inmunosupressed due to cancer treatment. Two of them started as febrile neutropenia and three as probable Cytomegalovirus co-infection.

Neumonía grave por Pneumocystis jirovecii en pacientes no HIV con enfermedades neoplásicas / Severe Pneumocystis jirovecci pneumonia in HIV-negative patients with neoplastic diseases

La neumonía por Pneumocystis jirovecii es una infección oportunista frecuente en pacientes positivos al VIH y CD4 < 200 células/mm3. Sin embargo, también se observa en pacientes inmunocomprometidos secundaria al tratamiento con inmunosupresores y altas dosis de esteroides. En estos pacientes, la neumonía grave de la comunidad o la neutropenia febril con infiltrados pulmonares difusos son las presentaciones clínicas más habituales; ambos cuadros cursan generalmente con hipoxemia severa. La falla respiratoria aguda con requerimientos de ventilación mecánica y alto riesgo de muerte intrahospitalaria ocurre con más frecuencia que en los pacientes positivos al VIH. El diagnóstico se realiza con tinción de Grocot, inmunofluorescencia indirecta (lFI) o PCR en lavado broncoalveolar. El tratamiento antibiótico debe incluir trimetoprim-sulfametozaxol y corticoides como adyuvantes. Es frecuente la coinfección con otros patógenos oportunistas, como citomegalovirus o Cándida albicans. Presentamos 4 pacientes VIH negativos, inmunosuprimidos por el tratamiento para enfermedades neoplásicas con neumonía grave por Pneumocystis jirovecii, dos de ellos en el contexto de neutropenia febril y tres con probable co-infección por ctfomegalovirus.(AU)

Pneumocystis jiroveciis pneumonia (PCP) is a well known and frequent opportunistic infection in HIV patients with a CD4 cell count under 200 cells/mm3. However, it can be seen in other inmunosupressed patients, secondary to the use of chemotherapy and high dose of steroids. The most common clinical manifestation are severe community-acquired pneumonia and fever with neutropenia plus diffuse lung infiltrates; generally severe hypoxemia is associated with both clinical manifestations. Acute respiratory failure requiring mechanical ventilation and a high risk of death at hospital are more frequent in HIV-negative than in HIV-positive patients. Diagnosis is achieved with Grocot stain, indirect immunofluorescence (IIF) or PCR, in bronchoalveolar lavage samples. Initial treatment should include cotrimoxazole, with adjuvant steroids. Coinfections with other opportunistic pathogens such a Cytomegalovirus or candlda albicans are frequent. The report describes 4 cases of Pneumocystis jirovecii pneumonia, in HIV negative patients, who are inmunosupressed due to cancer treatment. Two of them started as febrile neutropenia and three as probable Cytomegalovirus co-infection.(AU)

Acute treatment costs of intracerebral hemorrhage and ischemic stroke in Argentina.

BACKGROUND AND PURPOSE: Stroke is the third leading cause of death in Argentina, yet little information exists on the acute treatment provided for stroke or its costs. This study estimates the national costs of the acute treatment of first-ever intracerebral hemorrhage (ICH) and ischemic stroke (IS) in Argentina. METHODS: Retrospective hospital-based inception study design using data on resource use and costs from high-volume stroke centers in Argentina, and published population-based incidence data. Treatment provided at two large urban hospitals were evaluated in all patients admitted with a first-ever stroke between 1 January 2004 and 31 August 2006, and costs were assigned using appropriate unit cost data for all resource use. Cost estimates in Argentinian pesos were converted to US dollars ($) using the 2005 purchasing power parity index. National costs of acute treatment for incident strokes were estimated by extrapolation of average costs estimates to national incidence data. Assumptions of the average cost of stroke treatment on a national scale were examined in sensitivity analysis. RESULTS: The acute care of 167 patients with stroke was thoroughly evaluated from hospital admission to hospital discharge. Mean length of hospital stay was 35.4 days for ICH and 13.0 days for IS. Ninety-one percent of the patients with ICH and 68% of the patients with IS were admitted to an ICU for a mean length of stay (LOS) of 12.9 +/- 20.3 and 3.6 +/- 5.9 days respectively. Mean total costs of initial hospitalization were $12,285 (SD +/-14,336) for ICH and $3888 (SD +/-4018) for IS. Costs differed significantly by Glasgow Coma Scale (GCS) score at admission, development of pneumonia and infections during hospitalization, and functional outcome at hospital discharge. Aggregate national healthcare expenditures for acute treatment of incident ICH were $194.2m (range 97.1-388.4) and $239.9m for IS (range 119.9-479.7). CONCLUSION: The direct hospital costs of incident ICH and IS in Argentina are substantial and primarily driven by stroke severity, in-hospital complications and clinical outcomes. With the expected increase in the incidence of stroke over the coming decades, these results emphasize the need for effective preventive and acute medical care.

Tratamiento con caspofungina de endocarditis por Candida tropicalis resistente a fluconazol / Treatment with caspofungin of Candida tropicalis endocarditis resistant to fluconazol

Fungal endocarditis, in particular due to Candida species, requires medical and surgical treatment and amphotericin B is the drug of choice. Caspofungin is an echinocandin very effective against Candida and Aspergillus. We present a patient with Candida tropicalis endocarditis, fluconazol resistant, treated with caspofungin, on a compassional basis as a result of adverse effects with amphotericin B. The patient had a microbiological response.

Las endocarditis causadas por hongos, (Candida en particular), requieren tratamiento médico-quirúrgico,siendo la anfotericina B la droga de elección. Caspofungina es una equinocandina con gran actividadsobre Candida y Aspergillus. Se presenta un paciente con una endocarditis por Candida tropicalis resistente a fluconazol tratado con caspofungina bajo un esquema de salvataje, luego de haber presentado efectos adversos por anfotericina B. El paciente tuvo respuesta microbiológica.

Tratamiento con caspofungina de endocarditis por Candida tropicalis resistente a fluconazol / Treatment with caspofungin of Candida tropicalis endocarditis resistant to fluconazol

Fungal endocarditis, in particular due to Candida species, requires medical and surgical treatment and amphotericin B is the drug of choice. Caspofungin is an echinocandin very effective against Candida and Aspergillus. We present a patient with Candida tropicalis endocarditis, fluconazol resistant, treated with caspofungin, on a compassional basis as a result of adverse effects with amphotericin B. The patient had a microbiological response.(AU)

Las endocarditis causadas por hongos, (Candida en particular), requieren tratamiento médico-quirúrgico,siendo la anfotericina B la droga de elección. Caspofungina es una equinocandina con gran actividadsobre Candida y Aspergillus. Se presenta un paciente con una endocarditis por Candida tropicalis resistente a fluconazol tratado con caspofungina bajo un esquema de salvataje, luego de haber presentado efectos adversos por anfotericina B. El paciente tuvo respuesta microbiológica.(AU)

Plasminogen: an important hemostatic parameter in septic patients.

BACKGROUND: Previously we observed in some but not all septic patients a low plasma concentration of plasminogen. OBJECTIVES: To investigate prospectively whether plasma levels of plasminogen or the ratio of plasminogen to alpha-2-antiplasmin have a prognostic value for survival from sepsis and to study the variation of other hemostatic parameters during septicemia. PATIENTS: The study population consisted of 45 consecutive patients with septicemia, 15 non-septic patients from the same intensive care unit and 30 healthy volunteers. MEASUREMENTS AND MAIN RESULTS: Plasminogen concentrations were significantly lower (p < 0.001) in plasma of septic patients (median 0,62 IU/ml range: 0.15-1,06) than in plasma of healthy controls (median 1.00 IU/ml, range: 0.75-1.10) or of non-septic intensive care patients (median 1.00 IU/ml, range: 0.82-1.08). Among the other parameters tested, plasminogen activator inhibitor (PAI-1) antigen concentration and PAI activity were similar in septic and non-septic intensive care patients, but higher than in healthy controls. Concentrations of elastase-alpha-1-protease inhibitor or of thrombin-antithrombin complexes were higher in septic patients than in non-septic intensive care patients or healthy controls. A degraded form of plasminogen of 38 kDa was detected by Western blot analysis in the plasma of septic patients, but not in plasma of non-septic intensive care patients or controls. Plasminogen alone or the ratio of plasminogen to antiplasmin were good markers for survival from septicemia. E.g. for plasminogen at a cut off of 0.65 IU/ml, sensitivity was 90.5% and specificity 66.7%, whereas for the ratio of plasminogen over antiplasmin at a cut off ratio of 0,65 IU/ml, sensitivity was 95.2% and specificity 70.8%. CONCLUSION: Plasminogen or the ratio of plasminogen to antiplasmin are sensitive markers for survival in patients with septicemia.

Score de estratificación de riesgo en recuperación cardiovascular / Stratification risk score in the post-operative recovery of heart surgery

Para evaluar el pronóstico en relación con la mortalidad de los pacientes sometidos a cirugía con circulación extracorpórea se diseñó un puntaje compuesto por 21 ítems que incluyen variables pre, intra y posoperatorias. Los pacientes fueron evaluados con dicho puntaje al ingreso y a las 12 horas del posoperatorio inmediato. Se incluyeron 662 pacientes. Tras realizar el análisis estadístico se observó una diferencia significativa en la mortalidad de los pacientes con puntaje menor de 20 puntos y mayor o igual de 21 puntos. La mortalidad de pacientes con puntaje menor o igual a 20 puntos para cirugías programadas fue del 1,7 por ciento y con más de 20 puntos 36 por ciento (p< 0,00001). La mortalidad de pacientes con puntaje menor o igual a 20 puntos para cirugía de urgencia fue del 5,9 por ciento y de pacientes con puntaje superior a 20 puntos 45,5 por ciento (p< 0,01)

Score de estratificación de riesgo en recuperación cardiovascular / Stratification risk score in the post-operative recovery of heart surgery

Para evaluar el pronóstico en relación con la mortalidad de los pacientes sometidos a cirugía con circulación extracorpórea se diseñó un puntaje compuesto por 21 ítems que incluyen variables pre, intra y posoperatorias. Los pacientes fueron evaluados con dicho puntaje al ingreso y a las 12 horas del posoperatorio inmediato. Se incluyeron 662 pacientes. Tras realizar el análisis estadístico se observó una diferencia significativa en la mortalidad de los pacientes con puntaje menor de 20 puntos y mayor o igual de 21 puntos. La mortalidad de pacientes con puntaje menor o igual a 20 puntos para cirugías programadas fue del 1,7 por ciento y con más de 20 puntos 36 por ciento (p< 0,00001). La mortalidad de pacientes con puntaje menor o igual a 20 puntos para cirugía de urgencia fue del 5,9 por ciento y de pacientes con puntaje superior a 20 puntos 45,5 por ciento (p< 0,01) (AU)

Cost containment: the Americas. Argentina.

For many years, the evolution of Argentina's healthcare system has been influenced by political and economic instability. Inflation and hyperinflation have led to anarchic development of both health administration systems and hospitals. Critical care grew in a similar manner, resulting in a mix of > 500 critical care units with very different levels of technology and trained personnel. Cost-containment policies have been implemented mainly by health administration systems. Public institutions (university and large provincial and county hospitals) have suffered hard budget cuts that have resulted in a decrease in the quality of care and the loss of trained human resources. Union organizations, which cover the healthcare costs of > 60% of the population, implemented a low reimbursement policy that resulted in low standards of care for critically ill patients. The country's private hospital system is extremely heterogenous, ranging from little, simple institutions with a 20- to 30-bed capacity to great private institutions with international standards of care. Cost-containment efforts have been sporadic and isolated, and statistical data to analyze the results are lacking. In order to formulate a strategy of cost-containment in the near future, accreditation and categorization of critical care units and human resources training are being implemented by health authorities and the Argentine Society of Critical Care Medicine.