System In Argentina Research Articles

Budget impact of upadacitinib in patients with moderate to severe rheumatoid arthritis in Argentina.

To analyze the budget impact of upadacitinib (UPA) 15 mg + methotrexate (MTX) for the treatment of moderate-to-severe rheumatoid arthritis (RA) in patients with an inadequate response to conventional disease-modifying antirheumatic drugs (cDMARD-IR) from the perspective of social security and the private health sector in Argentina. A budget impact analysis model was developed for a hypothetical cohort of 100,000 adults with health insurance coverage who were diagnosed with RA over a 5-year time horizon. The model parameters were obtained through literature review and validated by local experts. The costs are expressed in 2024 US dollars (USD). The introduction of UPA 15 mg + MTX for the treatment of moderate-to-severe RA and cDMARD-IR resulted in minimal increase, with a five-year total cumulative incremental cost of USD 1,855 for social security and USD 1,812 for the private health sector, representing 2% of the total budget. The acquisition cost of UPA was the most influential variable in the sensitivity analysis. The introduction of UPA 15 mg + MTX for the treatment of moderate-to-severe RA and cDMARD-IR can provide an effective treatment option with a minimal increase in costs for the healthcare system in Argentina, which is especially important in developing countries where health system budgets are more limited. Providing evidence-based estimates is a valuable tool for informing healthcare policies and can help policymakers make informed decisions about the allocation of healthcare resources to improve patient outcomes while also managing costs.

Budget Impact Analysis of Olaparib in Combination with Bevacizumab for Maintenance Therapy for Ovarian Cancer in Argentina.

To perform a budget impact analysis (BIA) of introducing olaparib as maintenance therapy in women who have BRCA mutations (BRCAm) with platinum-sensitive recurrent ovarian cancer (PSROC) in combination with bevacizumab in Argentina. A BIA model was used to analyse over a 5-year time horizon the change in the health system's budget following the adoption of olaparib as maintenance therapy in BRCAm patients with PSROC. The BIA for each year was estimated by comparing the cost difference between the current scenario (treatment with bevacizumab) and the new scenario (the addition of olaparib) for a third-party payer. The BIA is estimated at the national health system level, and by healthcare sectors in Argentina (public sector, social security and private sector). International and national epidemiological data were used to determine the target patient population. Clinical efficacy, safety outcomes and duration of treatments were obtained from the pivotal clinical study report. Relevant direct medical costs were obtained from public data in Argentina and expert consultation. All the costs are reported in US dollars as of October 2022 ($1 = 152.59 Argentine pesos). A scenario analysis assessed the full coverage of the homologous recombination deficiency (HRD) test in Argentina. In addition, one-way sensitivity analysis was conducted to evaluate the model robustness. For a third-party payer with a cohort of 1,000,000 women covered, the estimated target population was 2 individuals in year 1 and 6 individuals in year 5. The incorporation of olaparib, with a wholesale price per pack of $3176.32, was associated with a weighted average of the budget impact per member per month (PMPM) of $0.062 for the national health system, being above the estimated health system budget impact threshold ($0.0153). By healthcare sector, the results of budget impact PMPM for year 5 ranged between $0.08 (public sector) and $0.114 (private sector). For all perspectives, the variables that most influenced the budget impact was the incidence of ovarian cancer, the drug acquisition cost and the treatment duration. The introduction of olaparib for the treatment of BRCAm women with PSROC has a high budget impact for all three health systems in Argentina.

Systems management strategies for increasing alfalfa use in warm‐humid regions

AbstractAlfalfa use (Medicago sativa L.; “lucerne”) in warm, humid regions of the world represents a potential area of expansion for the alfalfa industry. The objective of this review paper is to demonstrate how alfalfa forage breeding and systems research efforts have identified opportunities for increasing alfalfa contributions in these regions, along with potential pathways for seed industry and farming operations to increase adoption. Our review draws primarily on reports from the Southeast United States and Argentina. Significant technological advancements in plant screening and selection have identified alfalfa plant populations that are more adapted to the growing conditions experienced in these regions, which are often characterized by mild temperature, long growing seasons, and multiple other abiotic and biotic stressors. Management systems research conducted in the United States and Argentina has demonstrated the use of alfalfa for conserved forage, grazing, or dual‐purpose use in monoculture or mixtures with warm‐season grasses such as bermudagrass (Cynodon spp.). These trials report increased forage production, nutritive value, and ecosystem services of alfalfa–grass mixtures when compared with traditionally N‐fertilized warm‐season grass‐based systems. Grazing‐based alfalfa systems in Argentina have demonstrated methods for utilizing alfalfa as part of beef, dairy, and finishing systems. Some approaches for expanding alfalfa production in the region include targeted marketing efforts for adapted varieties and demonstrating alfalfa applications within existing farming frameworks. This includes educational programming efforts and on‐farm demonstrations to promote alfalfa use as a component of the livestock diets, integration into grass‐based systems, crop rotations, and wildlife use. Continued emphasis on a systems approach to alfalfa inclusion represents an opportunity for improved forage and livestock production in warm, humid regions of the world.

Pretreatment HIV-1 Resistance in Argentina: Results from the Second Surveillance Study Following World Health Organization Guidelines (2019).

More than 62,000 individuals are currently on antiretroviral treatment within the public health system in Argentina. In 2019, more than 50% of people on ART received non-nucleoside reverse transcriptase inhibitors (NNRTIs). In this context, the second nationwide HIV-1 pretreatment drug resistance surveillance study was carried out between April and December 2019 to assess the prevalence of HIV-1 drug resistance in Argentina using the World Health Organization guidelines. This was a nationwide cross-sectional study enrolling consecutive 18-year-old and older individuals starting ARVs at 19 ART-dispensing centers. This allowed us to estimate a point prevalence rate of resistance-associated mutations (RAMs) with a confidence interval (CI) of 5% (for the total population and for those without antiretroviral exposure). Four-hundred forty-seven individuals were included in the study. The prevalence of mutations associated with resistance was detected in 27.7% (95% CI 25.6-34.9%) of the population. For NNRTI, it was 19.6% (95% CI 16.3-24.5%), for integrase strand transfer inhibitor (INSTI) 6.1% (95% CI 6.1-11.9%), for nucleoside/nucleotide reverse transcriptase inhibitor (NRTI) 3% (95% CI 1.9-5.9%), and for protease inhibitors 1.5% (95% CI 0.7-3.6%). Naive individuals had variants of resistance to NRTIs in 16.8% (95% CI 12.8-21.4) and 5.7% (95% CI 2.9-15.9) to INSTI. For experienced individuals, the prevalence of variants associated with resistance was 30.38% (95% CI 20.8-42.2) for NRTIs and 7.7% (95% CI 2.9-15.9) for INSTI. This study shows an increase in the frequency of nonpolymorphic RAMs associated with resistance to NNRTI. This study generates the framework of evidence that supports the use of schemes based on high genetic barrier integrase inhibitors as the first line of treatment and the need for the use of resistance test before prescribing schemes based on NNRTI. We report for the first time the presence of a natural polymorphism associated with the most prevalent recombinant viral form in Argentina and the presence of a mutation linked to first-line integrase inhibitors such as raltegravir.

Response of forage production to drought in silvopastoral systems in Argentina

Response of forage production to drought in silvopastoral systems in Argentina

Cost of illness due to respiratory syncytial virus acute lower respiratory tract infection among infants hospitalized in Argentina

BackgroundInformation is scarce regarding the economic burden of respiratory syncytial virus (RSV) disease in low-resource settings. This study aimed to estimate the cost per episode of hospital admissions due to RSV severe disease in Argentina.MethodsThis is a prospective cohort study that collected information regarding 256 infants under 12 months of age with acute lower respiratory tract infection (ALRTI) due to RSV in two public hospitals of Buenos Aires between 2014 and 2016. Information on healthcare resource use was collected from the patient’s report and its associated costs were estimated based on the financial database and account records of the hospitals. We estimated the total cost per hospitalization due to RSV using the health system perspective. The costs were estimated in US dollars as of December 2022 (1 US dollar = 170 Argentine pesos).ResultsThe mean costs per RSV hospitalization in infants was US$587.79 (95% confidence interval [CI] $535.24 – $640.33). The mean costs associated with pediatric intensive care unit (PICU) admission more than doubled from those at regular pediatric wards ($1,556.81 [95% CI $512.21 – $2,601.40] versus $556.53 [95% CI $514.59 – $598.48]).ConclusionsThis study shows the direct economic impact of acute severe RSV infection on the public health system in Argentina. The estimates obtained from this study could be used to inform cost-effectiveness analyses of new preventive RSV interventions being developed.

Taphonomic analysis of Spinicaudata from two Triassic lacustrine systems affected by different volcanic processes

Spinicaudata are freshwater branchiopods. The growth and development of spinicaudata populations in freshwater environments depend on various physical, chemical, and biological factors. The action of volcanism modifies the limnological parameters in the process of fossilization of lacustrine deposits. This study identifies spinicaudatan assemblages in two Triassic lake systems in Argentina, and analyzes the dynamics of shell preservation according to the volcanic activity involved. Two taphonomic grades divided into three different second taphonomic grades were defined. The focus on taphonomic and chemistry studies addresses changes in spinicaudata abundance and richness through time, in different paleoenvironmental conditions, and shell preservation and chemical composition. The discussion highlights the importance of lava flow inflow and volcanic ash fall in the different lake systems. We emphasize the importance of taphonomic studies on the spinicaudata groups to understand their autochthonous and allochthonous populations in Triassic lake systems. In turn, we conclude that the post mortem processes experienced by the shells, the exposure time at the water-sediment interface, and the chemical alteration of the water into the paleolakes produced by the surrounding volcanic activity can explain the development and preservation of spinicaudata in these two Triassic lacustrine systems.

U-Pb Zircon Geochronology of Detrital and Ash Fall Deposits of the Southern Paraná Basin: A Contribution for Provenance, Tectonic Evolution, and the Paleogeography of the SW Gondwana

Zircon U-Pb geochronology was applied to investigate the provenance, depositional ages, and paleogeography of the southwestern Gondwana in detrital and ash fall sediments from Carboniferous to Jurassic succession of the southern Paraná Basin. Four detrital age populations suggest provenance from local and distal sources located to the south, southeast, and southwest: (i) Archean to Paleoproterozoic zircons from the Rio de La Plata Craton, Nico Peres and Taquarembó terranes; (ii) Grenvillian zircons from the basement of the Gondwanides and Namaqua–Natal belts; (iii) Neoproterozoic grains from the Don Feliciano Belt; and (iv) Phanerozoic populations from Paleozoic orogenic belts and related foreland systems in Argentina, as well as eroded units of the Paraná Basin. The paleogeographic reconstruction indicates an evolution in three distinct stages: (1) a gulf open to the Panthalassa Ocean during the Carboniferous; (2) an epicontinental sea with the rise of the Gondwanides Orogeny during the Permian; and (3) continental deposits controlled by an intra-plate graben system during the Triassic. Permian–Triassic volcanogenic zircons provide constrained maximum depositional ages and attested persistent volcanism, related to the Choiyoi magmatism and effects of the climate change episodes. During the Triassic, the extensional graben system recorded the uplift of the basement through regional northwest and northeast fault systems, and the recycling of Permian zircons, modifying source-to-sink relationships.

“One thing is the law, and another the medical practice”. Trans adolescents in the health system in Argentina: between the narratives of rights and adultcentrism

Resumen En Argentina, la legislación garantiza que las infancias y adolescencias trans puedan realizar el cambio de nombre y sexo en su documentación de acuerdo con su identidad autopercibida. Antes de los 16 años, deben presentar conformidad a través de sus representantes legales y contar con la asistencia de unx abogadx del niñx. Distintos espacios gubernamentales han construido protocolos de atención de salud integral despatologizantes que garantizan el acceso a procesos de modificación corporal con autonomía. Sin embargo, en la configuración de las intervenciones médicas, las narrativas de derechos se traman con la persistencia del cisexismo y del adultocentrismo. La autoridad epistémica de la ciencia, o la especialidad, suele anteponerse a las decisiones de lxs adolescentes. Abordo este problema a través del análisis de protocolos oficiales y entrevistas a profesionales de la salud en una ciudad intermedia de Buenos Aires.

Social epidemiology of COVID-19 in Argentina: an approach from the perspective of medical personnel

This article explores from a socio-epidemiological perspective the syndemic character acquired by the COVID-19 pandemic at the hospital level, belonging to the public health system in Argentina. Methodologically, semi-structured interviews were conducted with hospital workers from the southern area of the metropolitan region to the Federal Capital, by virtual meeting platforms, between the months of May and November 2021. The analysis of the narratives obtained about the experience of workers, makes it possible to understand certain dimensions that contribute to deepening the deterioration of working conditions, weakening and undermining the care and self-care processes of the workers themselves, linked not only to the imponderables of the pandemic being analyzed (while this occurs), but also to previous problems and are magnified during the epidemiological emergency. In this regard, the emergence of spaces for dialogue-collective work among workers is observed, as a fundamental cohesive force to promote any change or social transformation that materializes in a concrete way within the institution.

Diversified crop sequences to reduce soil nitrogen mining in agroecosystems

Nitrogen (N) is the primary driver of increased global food supply, but has environmental consequences from both under- and over-fertilisation. While over-fertilisation and reactive nitrogen release onto the environment is widespread in North America and Europe, under-fertilisation and soil mining prevail in South American croplands, calling for novel nitrogen-balancing strategies. The encroachment of soybean-centric, over-simplified cropping systems has eroded ecosystem services in South America. Here we compare the current soybean-centric system in Argentina with seven crop sequences in two long-term experiments started in 2008. Our aim was to identify alternative, more diverse crop sequences to maintain productivity and profitability with a close to neutral apparent N balance of the agroecosystem in two contrasting soils, i.e., a Mollisol and a Vertisol. Crop sequences combined locally adapted crops – soybean, maize and wheat for grain, field pea as cover crop – in a range from monocultures to complex sequences including all four crops. Crop sequence returned a 2.2–3.1-fold variation in productivity (from 4.7 to 10.9 Mg ha-1 in the Mollisol and from 3.4 to 9.9 Mg ha-1 in the Vertisol), 1.5-fold variation in profitability (from 0.92 to 2.14), variation in nitrogen balance from soil mining at − 35 kg N ha-1 year-1 to excess at 17 kg N ha-1 year-1, and a variation in nitrogen use efficiency at crop sequence level (NUEs) from 0.7 to 1.2 in both soil types. High soybean proportion reduced the NUEs and grain productivity of crop sequences. More complex crop sequences, i.e. including three/four crops, showed an N surplus and a similar grain yield than maize monoculture in both soils. The inclusion of maize into crop sequences with high cropping intensity increased both yield and NUEs. We identify new crop sequences that meet three conditions: high productivity and profitability, a close-to-neutral nitrogen balance, and a high nitrogen-use efficiency. These insights allow for alternatives to the current, unsustainable trajectories of simplified soybean-based systems that also avoid the path of over-fertilisation followed by cropping systems elsewhere.

Factors of the Revisit Intention of Patients in the Primary Health Care System in Argentina

The Argentine health system has three subsectors: private, social works, and public. It is essential to consider the user’s perceptions through studies that measure the intention to revisit, through self-perceived care quality, to obtain results from the health care process and adjust the services provided accordingly. A correlational, cross-sectional, and non-experimental study has been carried out. A total of 407 people were surveyed using a self-administered questionnaire with a five-point Likert scale. The model considered four variables: quality of the use of health programs, satisfaction, confidence, and revisit intention. Second-generation statistics were adopted through multivariate evaluation using partial least squares structural equation modeling (PLS-SEM) to calculate the correlation values between the study variables. The direct route between the quality of health services and satisfaction was not statistically significant, while the direct routes traced between the other constructs were statistically significant. This study contributes significantly to understanding how users determine the intention to re-choose a health service, explaining the indirect routes through which the quality of care relates to the intention to revisit.

Antimicrobial resistance dissemination associated with intensive animal production practices in Argentina: A systematic review and meta-analysis

Abuse and misuse of antimicrobial agents has accelerated the spread of antimicrobial-resistant bacteria. The association between antimicrobial-resistant infections in humans and antimicrobial use in agriculture is complex, but well-documented. This study provides a systematic review and meta-analysis of the dissemination of antimicrobial resistance (AMR) to antimicrobials defined as critically important by the WHO, in swine, chicken, and cattle from intensive and extensive production systems in Argentina. We conducted searches in electronic databases (MEDLINE-PubMed, Web of Science, SciELO, the National System of Digital Repositories from Argentina) as well as in the gray literature. Inclusion criteria were epidemiological studies on AMR in the main food-transmitted bacteria, Salmonella spp., Campylobacter spp., Escherichia coli and Enterococcus spp., and mastitis-causing bacteria, isolated from swine, chicken, dairy and beef cattle from Argentina. This study gives evidence for supporting the hypothesis that AMR of common food-transmitted bacteria in Argentina is reaching alarming levels. Meta-analyses followed by subgroup analyses confirmed the association between the prevalence of AMR and (a) animal species (p<0.01) for streptomycin, ampicillin and tetracycline or (b) the animal production system (p<0.05) for streptomycin, cefotaxime, nalidixic acid, ampicillin and tetracycline. Moreover, swine (0.47 [0.29; 0.66]) and intensive production (0.62 [0.34; 0.83]) showed the highest pooled prevalence of multidrug resistance while dairy (0.056 [0.003; 0.524]) and extensive production (0.107 [0.043; 0.240]) showed the lowest. A research gap regarding beef-cattle from feedlot was identified. Finally, there is an urgent need for political measures meant to coordinate and harmonize AMR surveillance and regulate antimicrobial use in animal production.

La gestión participativa del territorio en la conservación de los bosques y sus servicios ecosistémicos: Estudio de caso en la Argentina

Natural systems in Argentina have gradually faded as a consequence of land use change, resulting in a diminished capacity to provide the ecosystem services (ES) essential for the well-being of the communities. The basin of the Chocancharava River fits within that context and is immersed in an urban-agricultural matrix that has produced major forest fragmentation. Based on this socio-environmental problem, the present report recounts the challenges and possibilities pertaining to an experience in community management. First of all, a conservation-status assessment of the forest remnants was used as a steppingstone to convene the first meeting of institutions linked to the territory. This interagency coupling allowed for a more holistic diagnosis and the formulation of action plans. The first result was the creation of a peri-urban provincial reserve. Managing the reserve demanded a wider involvement from the community and the provision of a space where all possible voices could be heard. Therefore, the first participative workshop was held, in which ties with the environment were problematized through the ES framework. This experience was of importance when pondering about unilateral decision-making models and grasping the value of community-based networks to generate more inclusive policies. In addition, the workshop provided a space for the co-production of knowledge regarding main actors and tensions about natural resources uses. Furthermore, this process constituted a road of reflection regarding our practices, which are vital for new community processes with results that are legitimate and relevant for the socioecological transformation of the system.

CHILD PARTICIPATION IN FAMILY AND CHILD PROTECTION MATTERS IN ARGENTINA

The paper is part of a collaborative research organized by the International Association of Youth and FamilyJudges and Magistrates (AIMJF/IAYFJM) on child participation in family and protection matters. The article explainsthe legal, institutional and procedural aspects of child participation in the Justice System in Argentina

Gendered Imaginaries of Corruption – Perspectives from the Judicial System in Argentina

Gendered Imaginaries of Corruption – Perspectives from the Judicial System in Argentina

Changing Conditions for Local Food Actors to Operate Towards Agroecology During the COVID-19 Pandemic

Given the novel character of disturbances caused by the pandemic in food systems, initial studies have been conducted to stress the reinforced urgent need for food systems' transformation toward sustainability. First assessments, conducted in the early months of the pandemic, found that local food actors responded to changing production and marketing conditions by implementing alternative practices under the umbrella of agroecology. However, given the unprecedented and dynamic character of the pandemic in regional situations, and related context-specific changes caused in food system actors' operations, case studies are needed to assess in more detail under which changing conditions food actors implemented alternative practices. Moreover, the maintenance of practices as conditions normalize, and food actors' transformative potential in relation to the principles of agroecology, need further assessment. In response to these emerging issues, we provide insights into our case study research conducted during 2021 in a local food system in Argentina. The aim of this research was to study how changing conditions triggered local food actors to (re-)frame their objectives and activities regarding marketing, and to assess the relevance of agroecological principles as a means of responding to changing conditions and to unfold longer-term transitions. We identified local producer shops (n= 5) and markets (n= 4) that were established or consolidated by self-organized producer groups (SOPGs) during the first months of the pandemic. Using semi-structured interviews with SOPG members (n= 12) and qualitative content analysis, we found that alternative practices were adopted in response to different changing conditions, and new needs and opportunities for producers and consumers brought about by the pandemic. Objectives pursued, and activities undertaken by the groups revealed reactive short-term mitigation strategies, and proactive longer-term transformative objectives. The relational analysis between practices and agroecological principles showed that the principles became important means of responding to changing conditions and to unfold longer-term transitions. The cases illustrate how local food actors operationalized agroecological principles, and in turn how principles can be used to investigate the nature and potentials of food actors' alternative practices, highlighting the relevance of agroecology to co-design sustainability transitions in local food systems and to mitigate possible future crisis.

The need for coordination to develop customized competitiveness in agrifood systems: lemon, pork, and dairy in Argentina

PurposeThe purpose of this research is to analyze the ability of agrifood systems to construct “customized competitiveness” strategies that can allow firms to meet the specific and constantly changing demands of foreign markets.Design/methodology/approachThe research performs a comparative analysis of three case studies of agrifood systems in Argentina: lemon, pork, and dairy products. The authors obtained primary data from 79 semi-structured interviews with key persons in each agrifood system carried out online between March 2020 and February 2021. Secondary data was obtained from databases, academic studies, and reports from business associations and public agencies.FindingsThe authors find wide disparities in the development of customized competitiveness strategies between the studied agrifood systems (higher in lemon, lower in dairy products, and incipient in pork). The authors attribute the disparity to the varying degrees in which these systems are capable of coordinating their own actions and their interactions with State agencies.Originality/valueThe paper provides comparative evidence about the role of private coordination in the ability of agrifood systems to construct customized competitiveness strategies.

Operationalizing injustice. Criminal selectivity as a tool for understanding (and changing) criminalization in Argentina

This article proposes that the groundbreaking concept of “criminal selectivity” (Zaffaroni 2000, 2011, 2011b), not yet extensively used in the English literature, could benefit from a critical conceptualization and operationalization. The hope is that the resulting tools might facilitate the identification of the unfairness patterns and the subsequent transformation of the criminal justice system unequal functioning. To do so, this contribution will explore the framework of the notion of criminal selectivity to later describe how it displays at the two stages of the criminal justice process, i.e., primary and secondary criminalization. On the one hand, “primary criminalization” involves the enactment of statutes by legislators and the executive power. On the other hand, “secondary criminalization” encompasses the enforcement of the law by police officers; the court process by prosecutors, defense lawyers, judges, and juries; and the administration of punishment by correctional officers or parole boards. As none of these instances can possibly hold all the possible negative social behaviors accountable, an inquiry arises: what are the criteria to criminalize some behaviors and not others? Digging into this question, the article will provide some conceptual precision in relation to the mechanisms through which criminal selectivity operates. It will be argued that this filtering process works disregarding some behaviors and actors (under-criminalization) and focusing on others (over-criminalization) and that this different attitude responds to socio-economic grounds rather than to the involved social harm. Finally, building upon the described conceptual tools, the article analyzes the criminal justice system in Argentina.

Six-Month Glycemic Control with a Hybrid Closed-Loop System in Type 1 Diabetes Patients in a Latin American Country.

The goal of this study was to assess the 6-month effectiveness of hybrid closed loop on glycemic control in type 1 diabetes (T1D) patients in Latin America. An exploratory analysis of data prospectively collected from non-selected consecutive patients with T1D who initiated treatment with the MiniMed™ 670G system in Argentina was conducted. Baseline and follow-up visits at days 7, 28, 90, and 180 were carried out and data were downloaded at each visit. A total of 30 patients (age range 9-57 years, female 63.3%), 73.3% (n = 22) of whom previously used sensor augmented pump-predictive low glucose management (SAP-PLGM), with baseline glycated hemoglobin 7.4% ± 1% were included. Time in range between 70 and 180 mg/dL significantly increased from 65.1% at baseline to 77.3%, 76.2%, 75.7%, and 75.2% at days 7, 28, 90 and 180, respectively. Time above range (>180 mg/dL) significantly decreased from 33% to 22.5% (P < 0.001), while time below range (<70 mg/dL) did not change. Mean glucose levels were reduced from 163.5 mg/dL at baseline to 150.9 mg/dL (P = 0.001) at last visit. The Auto Mode feature was used > 90% of the time. Virtual training was successfully completed with a Net Promoter Score® (NPS®) of 87%. This analysis confirms that MiniMed 670G system use allowed successful achievement of glycemic control within recommended targets in a non-selected Latin American patient population who underwent virtual system training.