Tips to improve patient's experience in consultation / Consejos para mejorar la experiencia del paciente en la consulta

The physician­patient relationship is a complex consensual association based on trust, vulnerability, authority, empathy, and compassion1. Its main objective is to achieve the best patient health outcomes possible. Nonetheless, factors affect how the goal is achieved, such as ineffective communication and low emotional intelligence2. Historically, health professionals have recognized how relevant the physician­patient relationship is and the patient's experience. Accordingly, patient satisfaction positively impacts clinical effectiveness, health outcomes, patient safety, and adherence to preventive care actions, medication, and clinical practice3. That is why we consider that physicians must use different strategies to improve patients' experiences in consultation. Consequently, we aimed to describe a few tips for improving a patient's experience in consultation. Good communication is the main issue in the doctor­patient relationship, significantly affecting patient safety and satisfaction. According to Burgener, using the AIDET technique to communicate with patients will enhance their relationships with them. AIDET includes five communication behaviors: acknowledge, introduce, duration, explanation, and thank you. The technique consists of first acknowledging the patient by his name; also, the patient's companion, in the case, there is one, smiling and making eye contact (acknowledge). Second, the physician introduces themselves with their name, professional certification, and role in the patient's care (introduce). The next step is letting the patient know which phases of the consultation and the approximate duration of each. Furthermore, explaining to the patient what is next, seeing other physicians, the treatment to receive, laboratory tests, other issues, and answering questions (explanation). Finally, thank the patient for their communication and cooperation and thank the patient's companion for support4. Learning cultural metaphors of illness that is part of the cultural group is another vital strategy to improve communication5. Furthermore, explain the diagnosis and treatment options in a common language, using some active listening strategies to show the patient that you are paying attention. Using questions, affirmations, and non-verbal manifestations of attention, summarizing what they have said to make sure that you understand correctly6, and using the teach-back method, which consists of asking the patients to explain in their own words what they understood about their diagnosis, treatment, and self-care. These tools will also make communication more effective for both7. Other ways of enhancing the patient's experience are being empathetic by recognizing and understanding the patient's feelings, concerns, and situations. This will communicate that you know and care about what they need8 ­ starting the appointment at the scheduled time. Furthermore, if this is not possible, informing the patients about any delays will reduce anxiety and increase tolerance. Apologizing for the delays can positively impact emotions arising from the patient, such as irritation, anger, and frustration. Some ideas may include offering entertainment options such as magazines or televisions in the waiting room to make it more enjoyable9. Being empathetic is the foundation of the patient experience. We understand empathy as the ability to connect with others and see their situation from their perspective and context rather than from our values and life view. It begins with a warm and kindly initial contact, represented by direct eye contact, a respectful greeting appropriate to the patient's cultural background and age, and a welcoming statement that makes the patient feel comfortable and shows our genuine interest in helping them10. Following that, we ask the patient, in the most open-ended way possible, about the reasons for their visit to the clinic. This moment is crucial, but we recommend approaching it like news headlines. In other words, we only need a brief phrase that describes the different concerns of the patient. This moment may be intimidating for doctors, as we might think the patient will go on without limits, but 50% of patients will not take more than 90 s, and 90% will not take more than 3 min. The task, then, is to prioritize that list of issues and collectively determine if we can address all of them in this visit or if we need to defer some points from the list11. Next, we proceed to ask open-ended questions, actively listen, maintain a good posture, be mindful of our gestures, and, as mentioned before, use sounds and gestures to indicate that we are attentive and fully present with the patient. During this conversation, we pay attention to the emotional tone and cues regarding underlying concerns that may not be immediately apparent to respond empathetically. Finally, we summarize the information and ask the patient to clarify or provide further details on anything that may not have been fully understood. A third critical strategy is involving the patients in the decision-making process, which can be done by explaining the alternatives and the pros and cons. According to other authors, greater patient involvement in decision-making is associated with higher patient satisfaction12-14. Patient-reported outcome measures (PROMs) can also help improve patients' experiences. PROMs are standardized, validated surveys that can be used to assess various health-relevant concepts, including patient care experience. Using this tool, physicians and care providers can learn more about the patient's preferences and values, valuable information for shared decision-making, allowing the physician to propose treatment options that match the patient's preferences. It will also be possible to assess patient reports about their actual experiences with health-care services, giving them the opportunity to recognize which aspects need to be enhanced15. In addition, physicians who wear white coats are perceived as more reliable, experienced, friendly, and professional than those who do not wear white coats. This will impact patient satisfaction16-19. Accordingly, we suggest wearing white coats during consultations. Nevertheless, we may highlight that patients' preferences can vary according to different sociodemographic characteristics, such as age19. To conclude, we might like to emphasize that patients' well-being must be a vital physician's goal, which is why we encourage health-care professionals to put into practice the tips we describe in this document. Finally, thank the patient for their communication and cooperation. Furthermore, you may thank the patient's companion for their support

Assessing safety and efficacy of flexible ureteroscopy and laser lithotripsy in elderly patients / Evaluación de la seguridad y eficacia de la ureteroscopia flexible y la litotricia láser en pacientes de edad avanzada

Objective: The objective of the study was to determine the efficacy and safety of flexible ureteroscopy (F-URS) for the management of intrarenal or proximal ureteral lithiasis in aged patients. Materials and methods: In this retrospective, multicenter observational study, we collected the anonymized clinical data of patients who underwent F-URS at two institutions in Cali, Colombia between June 2015 and May 2018. The patients were divided into two groups based on age: Group A defined as aged patients (> 65 years) and Group B as patients of non-advanced age (< 65 years). Results: A total of 201 patients were included in this study. The average age for Group A was 75 years (± 4.5) and for Group B was 51 years (± 10). The anesthetic risk classification (American Society of Anesthesiology [ASA]) and comorbidities were significantly higher for Group A with an ASA II and III of 74% versus 50% in Group B. No significant differences were shown in the stone-free rates (SFRs) or significant ureteral injury (Grade III and IV). There was no difference in intraoperative or post-operative complications between both groups. Conclusions: Age > 65 years was not associated with a negative impact on the outcomes of F-URS for the management of intrarenal or proximal ureteral lithiasis in this cohort of patients. F-URS appears as a safe and effective procedure and should not be withheld from older patients

Objetivo: Determinar la efectividad y seguridad de la ureteroscopia flexible (F-URS) para el manejo de la litiasis ureteral intrarrenal o proximal en pacientes ancianos. Materiales y métodos: En este estudio observacional multicéntrico y retrospectivo, se recogieron los datos clínicos de los pacientes sometidos a F-URS en dos instituciones de Cali, Colombia, entre junio de 2015 y mayo de 2018. Los pacientes se dividieron en dos grupos según la edad. El grupo A se definió como pacientes de edad avanzada (> 65 años) y el grupo B como pacientes de edad no avanzada (< 65 años). Resultados: Un total de 201 pacientes fueron incluidos en este estudio. La edad media para el grupo A fue de 75 años (± 4,5) y para el grupo B fue de 51 años (± 10). La clasificación de riesgo anestésico (ASA) y las comorbilidades fueron significativamente mayores para el grupo A con un ASA II y III del 74% frente al 50% en el grupo B. No se observaron diferencias significativas en las tasas libres de cálculos ni en la lesión ureteral significativa (grado III y IV). No hubo diferencias en las complicaciones anestésicas, intraoperatorias o postoperatorias entre ambos grupos. Conclusiones: La edad > 65 años no se asoció con un impacto negativo en los resultados urológicos ni en la tasa de éxito de la F-URS para el manejo de la litiasis ureteral intrarrenal o proximal en esta cohorte de pacientes. La F-URS es un procedimiento seguro y eficaz, y no debe contraindicarse en los pacientes de edad avanzada

Lo particular que resulta el trato cosificante que se le da a una persona cuando se vuelve paciente / The particularity of the objectifying treatment of a person when he or she becomes a patient

La cosificación en salud representa una forma de trato peyorativo que el personal de salud da a sus pacientes. Este trato cosificante tiene su origen en la deshumanización en salud, que debido a los avances tecnológicos cada vez es más fuerte. Este es un problema multicausal, que un estudiante y médico pueden abordar desde un enfoque académico promoviendo activades que lleven a un fortalecimiento en la relación médico-paciente y la implementación de una política de humanización en cada institución

Reification in health care represents a form of pejorative treatment given by health care personnel to their patients. This objectifying treatment has its origin in the dehumanization of health, which due to technological advances is increasingly stronger. This is a multicausal problem, which a student and a physician can address from an academic approach promoting activities that lead to a strengthening of the doctor-patient relationship and the implementation of a humanization policy in each institution

Tips para un apropiado desenlace con el uso de las prótesis de pene / Tips for a proper outcome with the use of penile prostheses

Las prótesis peanas marcaron un cambio importante en la historia del manejo de la disfunción eréctil, principalmente en hombres refractarios a otros métodos existentes. En la actualidad se cuenta con tres opciones de implantes de prótesis peneanas: prótesis de dos piezas, de tres piezas y las semirrígidas; cada una de ellas con una indicación específica. Existen también diferentes tipos de abordajes quirúrgicos, de los cuales los más usados son el abordaje penoescrotal y suprapúbico. En cuanto a las complicaciones quirúrgicas, la infección es una de las más frecuentes, por lo que se han desarrollado implantes impregnados con antibióticos e implantes irrigables con solución antibiótica y/o antifúngicas a elección con el fin de mitigar la infección, puesto que se ha reportado que los dispositivos recubiertos reducen la incidencia de infección del dispositivo en aproximadamente un 50%, al igual que la implementación de otras técnicas como la de no tocar para reducir la infección. La prótesis peneana es una estrategia efectiva para el tratamiento de la disfunción eréctil en hombres refractarios a otras intervencione

Penile prostheses marked an important change in the history of erectile dysfunction management, mainly in men refractory to other existing methods. Currently, there are three options for penile prosthesis implants, which are: two-piece, three-piece and semi-rigid prostheses; each with a specific indication. There are also different types of surgical approaches, of which the most used are the penoscrotal and suprapubic approaches. Regarding surgical complications, infection is one of the most frequent, which is why implants impregnated with antibiotics and irrigable implants with antibiotic and/or antifungal solution of choice have been developed to mitigate infection, since it has been Coated devices have been reported to reduce the incidence of device infection by approximately 50%, as has the implementation of other techniques such as no-touch to reduce infection. Objective: This review aims to provide a detailed contextualization on the surgical management of erectile dysfunction with penile prosthesis implants, placement indications, types of prosthesis, placement tips, most used surgical approaches, and prevention of complications; with the objective of educating doctors and health personnel to become familiar with the procedure, better guide patients, and increase their satisfaction. Conclusions: The penile prosthesis is an effective strategy for the treatment of erectile dysfunction in men refractory to other interventions

Effectiveness and safety of prophylactic phototherapy to prevent jaundice in premature newborns: Systematic review and meta-analysis.

To determine the effectiveness and safety of prophylactic phototherapy compared with conventional phototherapy for the prevention of neonatal jaundice. We included clinical trials comparing prophylactic phototherapy to conventional phototherapy to prevent jaundice in premature newborns. We searched Embase, MEDLINE, LILACS, Central, and others. The statistical analysis was performed in RevMan (Review Manager 5.3). Outcomes were analyzed according to the type of variable: risk difference (RD) and mean difference (MD). A random effects model was used due to heterogeneity. We reported results in forest plots. Risk of bias was evaluated, and a sensitivity analysis was made. 1127 articles were found, and six studies (2332 patients) were included in the meta-analysis. Five studies evaluated the need for exchange transfusion as the primary outcome RD -0.01, 95% CI [-0.05 to 0.03]. One study evaluated bilirubin encephalopathy RD -0.04, 95% CI [-0.09 to 0.00]. Five studies evaluated the duration of phototherapy, MD 38.47, 95% CI [1.28 to 55.67]. Four studies evaluated levels of bilirubin (MD -1.23, 95% CI [-2.25 to -0.21]. Two studies evaluated mortality, RD 0.01, 95% CI [-0.03 to 0.04]. As a conclusion, compared to conventional phototherapy, prophylactic phototherapy decreases the last measured level of bilirubin, as well as the probability of neurodevelopmental disturbances. However, it increases phototherapy duration.

Manejo del cáncer de vejiga invasor de músculo con enfoque preservador de órgano: terapia trimodal / Management of muscle-invasive bladder cancer with an organ-sparing approach: trimodal therapy

El cáncer de vejiga es una patología frecuente del tracto genitourinario, cuyo tratamiento acarrea morbilidad y alteración de la calidad de vida y en particular en el subgrupo de pacientes con tumores vesicales clasificados como invasores de músculo. En los últimos años se han venido buscando alternativas terapéuticas para la cistectomía radical + linfadenectomía pélvica extendida, que es en la actualidad el estándar de manejo para los pacientes con carcinoma de vejiga invasor de músculo. Con el advenimiento de perfiles de manejo oncológico menos ablativos pero sin sacrificar resultados oncológicos y con las nuevas técnicas de radioterapia y quimioterapia, las modalidades terapéuticas preservadoras de órgano como la terapia trimodal (resección transuretral de tumor vesical + quimioterapia + radioterapia) se convierte en una alternativa terapéutica viable y con resultados oncológicos satisfactorios a largo plazo. Objetivo y metodología: Con esta revisión se pretende mostrar la actualidad de la terapia trimodal en el manejo de los tumores vesicales con invasión muscular, definir los mejores pacientes a considerar para recibir esta terapia, exponer los resultados oncológicos comparados con el estándar de manejo y los resultados en calidad de vida. También se propone un algoritmo de manejo y se presentar las recomendaciones al respecto en guías de práctica clínica. Conclusiones: La terapia trimodal es una alternativa al estándar de manejo que conduce a resultados oncológicos aceptables y puede considerarse una opción de tratamiento en pacientes bien seleccionados.

Introduction: Bladder cancer is a frequent pathology of the genitourinary tract, whose treatment causes morbidity and impaired quality of life, particularly in the subgroup of patients with bladder tumors classified as muscle invaders. In recent years, therapeutic alternatives have been sought for radical cystectomy + extended pelvic lymphadenectomy, which is currently the standard of care for patients with muscle-invasive bladder carcinoma. With the advent of less ablative oncological management profiles but without sacrificing oncological results and with new radiotherapy and chemotherapy techniques, organ-sparing therapeutic modalities such as trimodal therapy (transurethral resection of bladder tumor + chemotherapy + radiotherapy) becomes a viable therapeutic alternative with satisfactory long-term oncological results. Objective and methodology: This review aims to show the current status of trimodal therapy in the management of muscle-invasive bladder tumors, define the best patients to consider for receiving this therapy, present the oncological results compared with the management standard and the results in quality of life. A management algorithm is also proposed and recommendations in this regard are presented in clinical practice guidelines. Conclusions: Trimodal therapy is an alternative to standard management that leads to acceptable oncological outcomes and can be considered a treatment option in well-selected patients.

Trauma renal cerrado de alto grado: el rol de la angioembolización en el manejo secuencial / High-grade blunt renal trauma: the role of angioembolization in the sequential management

El trauma renal corresponde a un 10% de todos los traumas abdominales; de ellos, un 90% comprende el trauma cerrado. Con respecto a las intervenciones asociadas, el manejo secuencial conservador o «paso a paso¼ ha logrado disminuir las tasas de nefrectomía innecesarias, ubicándose en un 28% en la actualidad. Una de las herramientas disponibles en la actualidad como parte del tratamiento del paciente con trauma renal cerrado de alto grado es la angioembolización. Consecuentemente, vale la pena conocer cuáles son los factores predictores para realizar una intervención temprana con fines de detener el sangrado, las tasas de éxito de la primera o segunda angioembolización y los predictores de falla.

Renal trauma accounts for 10% of all abdominal traumas; of these, 90% comprise blunt trauma. With respect to associated interventions, sequential conservative or "step-by-step" management has managed to reduce unnecessary nephrectomy rates, currently standing at 28%. One of the tools currently available as part of the treatment of patients with high-grade blunt renal trauma is angioembolization. 2 Consequently, it is worth knowing the predictors of early intervention to stop bleeding, the success rates of the first or second angioembolization and the predictors of failure.

Conceptos básicos para aprender a llevar una vida con cáncer / Basic concepts for learning to live a life with cancer

El cáncer es una enfermedad altamente prevalente que afecta a millones de personas de todas las edades y más allá de comprometer la parte física del paciente, juega un papel muy importante en la salud no solo del enfermo, sino incluso de todo su núcleo familiar. Es bien conocido que los pacientes oncológicos tienen una mayor susceptibilidad y una mayor prevalencia a padecer trastornos clínicos psiquiátricos como ansiedad y depresión, y otros síntomas subclínicos que se pueden presentar en etapas tan tempranas como el diagnóstico, entre los que se encuentran: baja autoestima (debido a los cambios corporales producto del tratamiento: calvicie, cicatrices, amputaciones, etc.), miedo al tratamiento, culpa, enfado hacia sí mismo, negación, fatiga y preocupación por los otros, entre otros. En conjunto y sin una intervención adecuada, el gran distrés psicológico al que se enfrenta un paciente con cáncer en sus diferentes etapas puede afectar de forma muy negativa su calidad de vida, la adherencia al tratamiento, las relaciones familiares y sociales, e incluso aumentar la mortalidad de las personas diagnosticadas, como muestra un estudio de cohortes con 9.138 hombres diagnosticados con cáncer en el cual una baja resiliencia a estos estresores psicológicos anteriormente descritos aumentaron la tasa de mortalidad en un 61% en todos los tipos de cáncer.

Cancer is a highly prevalent disease that affects millions of people of all ages and beyond compromising the physical part of the patient, it plays a very important role in the health not only of the patient, but also of the entire family. It is well known that cancer patients have a greater susceptibility and a higher prevalence of clinical psychiatric disorders such as anxiety and depression, and other subclinical symptoms that can present themselves in stages as early as the diagnosis, among which are: low self-esteem (due to body changes resulting from the treatment: baldness, scars, amputations, etc.), fear of treatment, guilt, anger towards oneself, denial, fatigue and concern for others, among others. Taken together and without adequate intervention, the great psychological distress faced by a cancer patient in its different stages can negatively affect quality of life, adherence to treatment, family and social relationships, and even increase the mortality of those diagnosed, as shown in a cohort study of 9,138 men diagnosed with cancer in which low resilience to these psychological stressors described above increased the mortality rate by 61% in all types of cancer.

Enhancing the importance of value-based urology and uro-oncology / Realzar la importancia de la urología y la uro-oncología basadas en valores

With the ongoing advances and evolution in healthcare, we have witnessed new breakpoints in patient management. As a result, there have been tireless efforts to identify and eradicate barriers to care and minimize their impact on patients.

Con los continuos avances y la evolución de la asistencia sanitaria, hemos sido testigos de nuevos puntos de inflexión en la gestión de los pacientes. Como resultado, se han realizado incansables esfuerzos para identificar y erradicar las barreras a la atención y minimizar su impacto en los pacientes.

Abordaje quirúrgico de la aorta para urólogos / Surgical approach to the aorta for urologists

A propósito de un caso clínico surgió la pregunta, ¿los urólogos estamos familiarizados con el abordaje de las lesiones de la aorta abdominal o una de sus ramas? Teniendo en cuenta que dentro de nuestro accionar quirúrgico podríamos llegar a estar inmersos en una complicación de tipo vascular, es fundamental que conozcamos con detalle estas maniobras.

A clinical case raised the question: are urologists familiar with the approach to lesions of the abdominal aorta or one of its branches? Bearing in mind that in our surgical actions we could be involved in a vascular complication, it is essential that we know these maneuvers in detail.

Reducing medication errors for adults in hospital settings.

BACKGROUND: Medication errors are preventable events that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional or patient. Medication errors in hospitalised adults may cause harm, additional costs, and even death. OBJECTIVES: To determine the effectiveness of interventions to reduce medication errors in adults in hospital settings. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers on 16 January 2020.  SELECTION CRITERIA: We included randomised controlled trials (RCTs) and interrupted time series (ITS) studies investigating interventions aimed at reducing medication errors in hospitalised adults, compared with usual care or other interventions. Outcome measures included adverse drug events (ADEs), potential ADEs, preventable ADEs, medication errors, mortality, morbidity, length of stay, quality of life and identified/solved discrepancies. We included any hospital setting, such as inpatient care units, outpatient care settings, and accident and emergency departments. DATA COLLECTION AND ANALYSIS: We followed the standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care (EPOC) Group. Where necessary, we extracted and reanalysed ITS study data using piecewise linear regression, corrected for autocorrelation and seasonality, where possible.  MAIN RESULTS: We included 65 studies: 51 RCTs and 14 ITS studies, involving 110,875 participants. About half of trials gave rise to 'some concerns' for risk of bias during the randomisation process and one-third lacked blinding of outcome assessment. Most ITS studies presented low risk of bias. Most studies came from high-income countries or high-resource settings. Medication reconciliation -the process of comparing a patient's medication orders to the medications that the patient has been taking- was the most common type of intervention studied. Electronic prescribing systems, barcoding for correct administering of medications, organisational changes, feedback on medication errors, education of professionals and improved medication dispensing systems were other interventions studied. Medication reconciliation Low-certainty evidence suggests that medication reconciliation (MR) versus no-MR may reduce medication errors (odds ratio [OR] 0.55, 95% confidence interval (CI) 0.17 to 1.74; 3 studies; n=379). Compared to no-MR, MR probably reduces ADEs (OR 0.38, 95%CI 0.18 to 0.80; 3 studies, n=1336 ; moderate-certainty evidence), but has little to no effect on length of stay (mean difference (MD) -0.30 days, 95%CI -1.93 to 1.33 days; 3 studies, n=527) and quality of life (MD -1.51, 95%CI -10.04 to 7.02; 1 study, n=131).  Low-certainty evidence suggests that, compared to MR by other professionals, MR by pharmacists may reduce medication errors (OR 0.21, 95%CI 0.09 to 0.48; 8 studies, n=2648) and may increase ADEs (OR 1.34, 95%CI 0.73 to 2.44; 3 studies, n=2873). Compared to MR by other professionals, MR by pharmacists may have little to no effect on length of stay (MD -0.25, 95%CI -1.05 to 0.56; 6 studies, 3983). Moderate-certainty evidence shows that this intervention probably has little to no effect on mortality during hospitalisation (risk ratio (RR) 0.99, 95%CI 0.57 to 1.7; 2 studies, n=1000), and on readmissions at one month (RR 0.93, 95%CI 0.76 to 1.14; 2 studies, n=997); and low-certainty evidence suggests that the intervention may have little to no effect on quality of life (MD 0.00, 95%CI -14.09 to 14.09; 1 study, n=724).  Low-certainty evidence suggests that database-assisted MR conducted by pharmacists, versus unassisted MR conducted by pharmacists, may reduce potential ADEs (OR 0.26, 95%CI 0.10 to 0.64; 2 studies, n=3326), and may have no effect on length of stay (MD 1.00, 95%CI -0.17 to 2.17; 1 study, n=311).  Low-certainty evidence suggests that MR performed by trained pharmacist technicians, versus pharmacists, may have little to no difference on length of stay (MD -0.30, 95%CI -2.12 to 1.52; 1 study, n=183). However, the CI is compatible with important beneficial and detrimental effects. Low-certainty evidence suggests that MR before admission may increase the identification of discrepancies compared with MR after admission (MD 1.27, 95%CI 0.46 to 2.08; 1 study, n=307). However, the CI is compatible with important beneficial and detrimental effects. Moderate-certainty evidence shows that multimodal interventions probably increase discrepancy resolutions compared to usual care (RR 2.14, 95%CI 1.81 to 2.53; 1 study, n=487). Computerised physician order entry (CPOE)/clinical decision support systems (CDSS) Moderate-certainty evidence shows that CPOE/CDSS probably reduce medication errors compared to paper-based systems (OR 0.74, 95%CI 0.31 to 1.79; 2 studies, n=88).  Moderate-certainty evidence shows that, compared with standard CPOE/CDSS, improved CPOE/CDSS probably reduce medication errors (OR 0.85, 95%CI 0.74 to 0.97; 2 studies, n=630). Low-certainty evidence suggests that prioritised alerts provided by CPOE/CDSS may prevent ADEs compared to non-prioritised (inconsequential) alerts (MD 1.98, 95%CI 1.65 to 2.31; 1 study; participant numbers unavailable). Barcode identification of participants/medications Low-certainty evidence suggests that barcoding may reduce medication errors (OR 0.69, 95%CI 0.59 to 0.79; 2 studies, n=50,545). Reduced working hours Low-certainty evidence suggests that reduced working hours may reduce serious medication errors (RR 0.83, 95%CI 0.63 to 1.09; 1 study, n=634). However, the CI is compatible with important beneficial and detrimental effects. Feedback on prescribing errors Low-certainty evidence suggests that feedback on prescribing errors may reduce medication errors (OR 0.47, 95%CI 0.33 to 0.67; 4 studies, n=384). Dispensing system Low-certainty evidence suggests that dispensing systems in surgical wards may reduce medication errors (OR 0.61, 95%CI 0.47 to 0.79; 2 studies, n=1775). AUTHORS' CONCLUSIONS: Low- to moderate-certainty evidence suggests that, compared to usual care, medication reconciliation, CPOE/CDSS, barcoding, feedback and dispensing systems in surgical wards may reduce medication errors and ADEs. However, the results are imprecise for some outcomes related to medication reconciliation and CPOE/CDSS. The evidence for other interventions is very uncertain. Powered and methodologically sound studies are needed to address the identified evidence gaps. Innovative, synergistic strategies -including those that involve patients- should also be evaluated.

Salud intercultural y el modelo de salud propio indígena / Intercultural health and the indigenous health model

RESUMEN La población indígena tiene condiciones de vida inferiores al resto, reflejadas en mayor morbilidad y mortalidad a pesar de la cobertura del Sistema de Salud. Por ello, es importante conocer las causas de estas diferencias. Para esto, se hace uso de la interculturalidad como puente entre la cultura occidental y la cultura indígena. En este encuentro de saberes se identifica el modelo de salud indígena como respuesta cultural a la necesidad de mantener la salud y tratar la enfermedad, un modelo organizado jerárquicamente en el que la salud del individuo depende además de sus hábitos, de la armonía con la naturaleza, el espíritu, los dioses y su comunidad. Este modelo había sido menospreciado hasta hace poco tiempo por la comunidad científica; pero, gracias a los estudios en interculturalidad, se sabe que la salud también debe ser intercultural y que las políticas públicas deben incluirla para poder obtener los resultados esperados en la comunidad objetivo. Para hacer realidad estas políticas públicas debe haber voluntad y agenda política, una adecuada estructura en los servicios de salud y formación de los profesionales de la salud en interculturalidad desde sus estudios técnicos, tecnológicos, profesionales y de posgrado. Esas políticas públicas deben contener: capacitación, empleo de la lengua indígena local, alimentación y equipamiento con elementos tradicionales, diálogo respetuoso con los médicos tradicionales, atención humanizada, entre otros. Así se brinda una atención en salud de calidad que respeta las diferencias culturales de toda la población.(AU)

ABSTRACT The indigenous population has lower living conditions reflected in higher morbidity and mortality despite the coverage of the Health System, so it is important to know the causes of these differences. For this, Interculturality is used as a bridge between western culture and indigenous culture. In this meeting of knowledge, the indigenous health model is identified as a cultural response to the need to maintain health and treat disease, a hierarchically organized model in which the health of the individual also depends on their habits, on harmony with nature, the spirit, the gods and their community. Until recently, this model had been undervalued by the scientific community, but thanks to studies in Interculturality, it is known that health must also be intercultural and that public policies must include it in order to obtain the expected results in the target community. To make these public policies a reality, there must be a will and a political agenda, an adequate structure in the health services and training of health professionals in interculturality from their technical, technological, professional and postgraduate studies. These public policies must contain training, use of the local indigenous language, food and equipment with traditional elements, respectful dialogue with traditional doctors, humanized care, among others. This provides quality health care that is respectful of cultural differences to the entire population.(AU)

[Intercultural health and the indigenous health model]. / Salud intercultural y el modelo de salud propio indígena.

The indigenous population has lower living conditions reflected in higher morbidity and mortality despite the coverage of the Health System, so it is important to know the causes of these differences. For this, Interculturality is used as a bridge between western culture and indigenous culture. In this meeting of knowledge, the indigenous health model is identified as a cultural response to the need to maintain health and treat disease, a hierarchically organized model in which the health of the individual also depends on their habits, on harmony with nature, the spirit, the gods and their community. Until recently, this model had been undervalued by the scientific community, but thanks to studies in Interculturality, it is known that health must also be intercultural and that public policies must include it in order to obtain the expected results in the target community. To make these public policies a reality, there must be a will and a political agenda, an adequate structure in the health services and training of health professionals in interculturality from their technical, technological, professional and postgraduate studies. These public policies must contain training, use of the local indigenous language, food and equipment with traditional elements, respectful dialogue with traditional doctors, humanized care, among others. This provides quality health care that is respectful of cultural differences to the entire population.

La población indígena tiene condiciones de vida inferiores al resto, reflejadas en mayor morbilidad y mortalidad a pesar de la cobertura del Sistema de Salud. Por ello, es importante conocer las causas de estas diferencias. Para esto, se hace uso de la interculturalidad como puente entre la cultura occidental y la cultura indígena. En este encuentro de saberes se identifica el modelo de salud indígena como respuesta cultural a la necesidad de mantener la salud y tratar la enfermedad, un modelo organizado jerárquicamente en el que la salud del individuo depende además de sus hábitos, de la armonía con la naturaleza, el espíritu, los dioses y su comunidad. Este modelo había sido menospreciado hasta hace poco tiempo por la comunidad científica; pero, gracias a los estudios en interculturalidad, se sabe que la salud también debe ser intercultural y que las políticas públicas deben incluirla para poder obtener los resultados esperados en la comunidad objetivo. Para hacer realidad estas políticas públicas debe haber voluntad y agenda política, una adecuada estructura en los servicios de salud y formación de los profesionales de la salud en interculturalidad desde sus estudios técnicos, tecnológicos, profesionales y de posgrado. Esas políticas públicas deben contener: capacitación, empleo de la lengua indígena local, alimentación y equipamiento con elementos tradicionales, diálogo respetuoso con los médicos tradicionales, atención humanizada, entre otros. Así se brinda una atención en salud de calidad que respeta las diferencias culturales de toda la población.

First Line Treatments for Newly Diagnosed Primary Immune Thrombocytopenia in Children: A Systematic Review and Network Meta-analysis.

BACKGROUND: The first-line interventions in immune thrombocytopenia (ITP) include intravenous polyclonal immunoglobulins (IVIg), corticosteroids and anti-D immunoglobulin (anti-D). OBJECTIVE: We aimed to compare the effectiveness and safety of first line treatments for newlydiagnosed primary ITP in children to increase the platelet count. METHODS: We searched MEDLINE, EMBASE, LILACS and the Cochrane Central register of Controlled Trials (CENTRAL); and included the clinical trials. We performed the statistical analysis in R. RESULTS: We included 12 studies for meta-analysis. Compared with IVIG 2g/kg, response rates were lower for prednisone 2mg/kg at 72 hours [RR 0.04 (95% CI 0.0 to 0.68)] and at 7 days [RR 0.23 (95% CI 0.08 to 0.67)]; at 48 hours, methylprednisolone 30mg/kg also showed lower response rates [RR 0.72 (95% CI 0.52 to 0.99)]. IVIG 2g/kg and 2.5g/kg had less adverse effects than Anti- D, methylprednisolone and IVIG 0.8g/kg. For rising platelet count, no statistical differences were found at 24 hours or in 7 days; at 48 hours, IVIG 2g/kg showed better results than Anti-D 75µg/kg [MD -58.84 (95% CI -87.02 to -25.66)]. After a month, platelet count with IVIG 2g/kg was higher than Anti-D 50 and 75µg/kg [-82.03 (95% CI -102.60 to -61.46) and -78.77 (95% CI -97.80 to - 59.74), respectively], but lower than methylprednisolone 50mg/kg [MD 118 (95% CI 3.88 to 232.12)]. CONCLUSION: The total platelet count rises higher in early and late phases with IVIG than Anti-D, but in long term it is higher with methylprednisolone. Additionally, IVIG causes less adverse effects than Anti-D and corticosteroids.

Role of cytoreductive nephrectomy in the targeted therapy era: A systematic review and meta-analysis.

Purpose: To determine the effectiveness and harm of cytoreductive nephrectomy versus no intervention in patients with metastatic renal carcinoma who undergo targeted therapy to improve overall survival. Materials and Methods: A search strategy was conducted in the MEDLINE, CENTRAL, Embase, HTA, DARE, NHS, and LILACS databases. Searches were also conducted for unpublished literature through references from relevant articles identified through the search, conferences, thesis databases, OpenGrey, Google Scholar, and clinicaltrials.gov, among others. Studies were included without language restrictions. The risk of bias assessment was made by using a modified Cochrane Collaboration tool. A meta-analysis of fixed effects was conducted. The expected outcomes were overall survival, quality of life, adverse effects, mortality, and progression- free survival. The measure of the effect was the hazard ratio (HR) with a 95% confidence interval (CI). The planned comparison was cytoreductive nephrectomy versus no intervention. Results: A total of 22,507 patients were found among seven studies. Seven studies were included in the qualitative analysis (eight publications) and five in the quantitative analysis for overall survival. One study reported progression-free survival and one reported targeted therapy toxicities. A low risk of bias was shown for most of the study items. The HR for overall survival was 0.58 (95% CI, 0.50 to 0.65) favoring cytoreductive nephrectomy compared with no intervention. Conclusions: Cytoreductive nephrectomy is effective for improving overall survival in patients with metastatic renal carcinoma who undergo targeted therapy compared with no intervention.

Dengue perinatal: Reporte de caso / Perinatal Dengue: A case Report

Resumen Introducción: El dengue perinatal es una patología de la que poco se sabe, los reportes disponibles describen riesgo de resultados perinatales adversos. Objetivo: Reportar un caso de dengue perinatal, como diagnóstico diferencial de sepsis neonatal, que debe tenerse en cuenta en zonas endémicas. Caso clínico: Recién nacido de una mujer de 23 años quien a las 36 semanas de gestación presentó cuadro de dengue con antígeno Non-Structural Protein 1 (NS1) positivo y anticuerpos anti-dengue negativos. Al sexto día de enfermedad dio a luz a un recién nacido sano, quien, al segundo día de vida, presentó fiebre sin otros hallazgos patológicos al examen físico, asociado a trombocitopenia severa (17.900 plaquetas/uL) y aumento de la proteína C reactiva, antígeno viral NS1 positivo e in-munoglobulina G (IgG) anti dengue positiva. Fue manejado con antibióticoterpia con ampicilina y gentamicina por protocolo de la institución para sepsis neonatal probable. El neonato mostró me joría clínica, con estabilidad hemodinámica y aumento significativo de plaquetas, siendo dado de alta. Conclusiones: El dengue en el embarazo trae consigo el riesgo de resultados perinatales adver sos, particularmente bajo peso al nacer y parto pre-término. Los hijos de madres diagnosticadas con dengue al final del embarazo deberían ser observados estrechamente con realización de hemograma seriado en los primeros días de vida, debido al riesgo de transmisión vertical.

Abstract Introduction: Few reports are available about perinatal dengue, with controversial results in regards the risk of perinatal outcome. Objective: To report a case of perinatal dengue as a differential diagno sis with neonatal sepsis, which must be considered in endemic areas. Clinical case: Male newborn of a 23 year-old female, who presented a Non-Structural Protein 1 (NS1) antigen positive to dengue at 36 weeks of gestation and negative anti-dengue antibodies. At day six of the illness a healthy newborn was born. On the second day of life the neonate presented fever with no other pathological findings on the physical exam, associated with severe thrombocytopenia (17,900 platelets/uL), increased C-reactive protein, a positive NS1 antigen, and positive anti-dengue immunoglobulin G (IgG). He was treated with ampicillin and gentamicin according the Institution protocol of neonatal sepsis. The newborn showed clinical improvement, with hemodynamic stability and significant increase of platelets, receiving the medical discharge. Conclusions: Dengue in pregnancy produces the risk of adverse perinatal outcomes, particularly low birth weight and preterm delivery. Children of mothers diagnosed with dengue at the end of pregnancy should be observed closely with serial hemograms during child's first days of life, due to the high risk of vertical transmission.

[Perinatal Dengue: A case Report]. / Dengue perinatal: Reporte de caso.

INTRODUCTION: Few reports are available about perinatal dengue, with controversial results in regards the risk of perinatal outcome. OBJECTIVE: To report a case of perinatal dengue as a differential diagno sis with neonatal sepsis, which must be considered in endemic areas. CLINICAL CASE: Male newborn of a 23 year-old female, who presented a Non-Structural Protein 1 (NS1) antigen positive to dengue at 36 weeks of gestation and negative anti-dengue antibodies. At day six of the illness a healthy newborn was born. On the second day of life the neonate presented fever with no other pathological findings on the physical exam, associated with severe thrombocytopenia (17,900 platelets/uL), increased C-reactive protein, a positive NS1 antigen, and positive anti-dengue immunoglobulin G (IgG). He was treated with ampicillin and gentamicin according the Institution protocol of neonatal sepsis. The newborn showed clinical improvement, with hemodynamic stability and significant increase of platelets, receiving the medical discharge. CONCLUSIONS: Dengue in pregnancy produces the risk of adverse perinatal outcomes, particularly low birth weight and preterm delivery. Children of mothers diagnosed with dengue at the end of pregnancy should be observed closely with serial hemograms during child's first days of life, due to the high risk of vertical transmission.