Exploring language barriers to Evidence-based Health Care (EBHC) in post-graduate medical students: a randomised trial.

BACKGROUND: Understanding the written English language might be a barrier when teaching Evidence-based Health Care (EBHC) to Spanish-speaking physicians. AIM: To quantify the magnitude of this potential barrier. METHOD: Cochrane Review abstracts in English or in Spanish were randomly distributed among first-year residents at the Pontificia Universidad Catolica of Chile. Residents answered investigator-designed questionnaires to measure their comprehension while the time needed to complete the task was recorded. RESULTS: Groups were similar at baseline. Mean score for those reading in Spanish was 11.9 +/- 2.8 (range 5 to 18) compared to 10.5 +/- 3.8 (range 1 to 17) for those reading in English (p=0.04). Low scores ( pound 9) were twice as frequent for the English group than for the Spanish group (16.7% vs 34.7%; p=0.042). The time to complete the task was also longer for the group reading in English. CONCLUSION: Language should be taken into account when teaching EBHC to Spanish-speaking physicians.

La medicina basada en evidencia. Visión después de una década / Evidence based medicine: a view after a decade

Evidence based medicine (EBM) appeared early in the 1990s and since then it has been developed and expanded worldwide. A decade later we summarize the history of EBM, the initial debates and the evolution to the current concept of evidence based health care (EBHC) as a tool for clinical decision making. We also describe the process of EBHC, some insights to current dilemmas and the situation of EBM in Chile.

Clinical estimation of trunk position among mechanically ventilated patients.

OBJECTIVES: Trunk position at 45 degrees from the horizontal is associated with a decreased risk of gastroesophageal aspiration. The objectives of this study were to determine the accuracy of trunk flexion estimates compared to a reference standard measurement, and to determine agreement about trunk flexion among ICU clinicians. DESIGN: Prospective observational study. SETTING: Two university-affiliated medical-surgical ICUs. PATIENTS AND PARTICIPANTS: Thirty-three mechanically ventilated ICU patients, seven residents, two fellows, three intensivists, and twenty-eight bedside nurses. INTERVENTIONS: Prospectively, concurrently, and independently during rounds, one bedside nurse, one resident, one fellow, and one intensivist clinically estimated the trunk flexion of mechanically ventilated patients. To record the reference standard, a trained investigator measured trunk position in the vertical plane using a goniometer. MEASUREMENTS AND RESULTS: We made 438 clinical assessments on 33 patients aged 57.2+/-19.4 (SD) years with an APACHE II score of 27.3+/-9.4. Mean trunk flexion estimates were: nurses 24.3+/-12.3 degrees from the horizontal, residents 20.2+/-13.7, fellows 20.3+/-10.8, and intensivists 21.1+/-13.1 compared to the reference standard measurement 16.2+/-9.0 degrees. The accuracy of trunk flexion estimates was fair to moderate [intraclass correlation for reference standard versus nurses (ICC 0.42), residents (ICC 0.52), fellows (ICC 0.36), and intensivists (ICC 0.55)]. The agreement among different groups of clinicians was moderate. CONCLUSIONS: In mechanically ventilated patients, we found that clinical estimates of trunk position were moderately good, agreement amongst caregivers was moderately good, but that all clinicians tended to overestimate the angle of semirecumbency.

[Clinical epidemiologic study of patients admitted to the intensive care unit, according to age]. / Estudio clínico epidemiológico de los pacientes ingresados a UCI, según grupo etáreo.

BACKGROUND: Lately, we have observed an increase in the admission to intensive care units of patients over 65 years old, probably due to the increase in life expectancy that is occurring in Chile. AIM: To compare the frequency of admissions to intensive care units in patients over 65 years old, their diagnoses, their severity and hospital course, with those of younger patients. PATIENTS AND METHODS: The charts of all patients admitted to an intensive care unit of a University Hospital, during one year, were reviewed. The diagnosis that caused the admission was considered the main disease. Severity at the moment of admission was assessed using the Apache score. RESULTS: A total of 777 patients were admitted during the study period. Twenty had to be excluded due to lack of reliable data. Four hundred thirty two (57%) were over 65 years old. Cardiovascular diseases were the main cause of admission in young and old patients. Mortality was 14.8% of patients over 65 years old and 18.7% in younger patients. Main causes of death were cardiac arrest, cardiogenic shock, sepsis and cerebrovascular disease. No differences in causes of death were observed between young and old patients. CONCLUSIONS: Patients older than 65 years old admitted to intensive care units are very similar to their younger counterparts in their prognosis and causes of admission.

[Study of the survival of elderly patients in intensive care units. Should they be admitted to these units?]. / Estudio de sobrevida de los pacientes adultos mayores en unidades de cuidado intensivo: deben ingresar?

BACKGROUND: An important increase in health care costs has occurred lately, determined in part by the expenses of intensive care units. An important proportion of beds in these units are occupied by elders, with high costs and dubious results. AIM: To study the survival of elderly patients in intensive care units to shed light on the question if these patients should be admitted to these facilities. MATERIAL AND METHODS: We retrospectively analyzed the mortality of 443 patients older than 65 years old, admitted to an intensive care unit between 1993 and 1994. The mortality was compared with that of 334 younger patients admitted in the same period. Severity of disease was determined using admission APACHE II score. RESULTS: Older patients had a higher admission APACHE score than younger subjects (18.4 +/- 8.4 and 14.5 +/- 8.7 respectively, p < 0.01). Mortality during the intensive care unit stay was similar in older and younger patients (18.5 and 14.4%, respectively). Hospital mortality was also similar (22.4 and 25.9%, respectively). Older patients had a higher frequency of chronic diseases and degree of functional impairment. Mortality rates for different diseases were also similar in older and younger patients. CONCLUSIONS: Older age was not associated with a higher mortality during intensive care unit stay. Prognosis is determined by the admission severity score and the number of concomitant chronic diseases.

[Inhibition of the nitric oxide pathway in refractory septic shock]. / Inhibición de la vía del óxido nítrico en el shock séptico refractario.

AIM: To assess the acute effects of methylene blue infusion, an inhibitor of nitric oxide synthesis, on hemodynamic parameters in patients with refractory septic shock. PATIENTS AND METHODS: Fourteen patients admitted to intensive care units with septic shock of diverse etiologies and unable to maintain median arterial pressures over 60 mm Hg with the use of at least 2 vasoactive drugs, were studied. All received a 1 mg/kg bolus of methylene blue Hemodynamic parameters were measured before and 30, 60, 120 and 180 min after the bolus. RESULTS: Systolic and diastolic blood pressure and systemic vascular resistance increased in all patients. There were no significant changes in cardiac output, oxygen consumption or extraction. CONCLUSIONS: Methylene blue has an acute pressor effect in patients with septic shock.

On the rate of tubal pregnancy contralateral to the corpus luteum.

Ectopic implantation of the embryo in the tube opposite to the ovary containing the corpus luteum constitutes evidence of peritoneal or uterine transmigration of the egg. The frequency of this phenomenon was reinvestigated utilizing histopathologic confirmation of the side of the corpus luteum. A tubal pregnancy contralateral to the ovulating ovary was found in 28% of 67 cases, indicating that either the oocyte, the zygote or the embryo had entered the tube in which implantation took place from a medial site such as the peritoneal or the uterine cavity rather than directly from the ovulating ovary. Assuming that once in the medial site there is equal chance of entering either tube, it follows that in 56% of tubal pregnancies the egg has entered the tube from a midline location. Attempts to recover the oocyte from the tubes in normal women were successful in fewer than 5% of cases contralateral to the corpus luteum. It is concluded that tubal pregnancy is associated with a significant increase in the occurrence of transmigration of the egg.