Trajetórias e determinantes do alto risco cardiovascular de 30 anos entre participantes de uma coorte brasileira (Estudo CUME) / Trajectories and determinants of 30-year high cardiovascular risk among participants in a Brazilian cohort (CUME Study)

Introdução: As doenças cardiovasculares são o principal problema de saúde pública em todo o mundo. Portanto, a avaliação do risco cardiovascular, com a identificação de seus fatores de risco e de proteção e de suas trajetórias ao longo do tempo são importantes para a proposição, a consolidação e a implementação de medidas de prevenção da ocorrência de doenças cardiovasculares. Objetivo geral: Analisar a trajetória e os determinantes do alto risco cardiovascular de 30 anos em participantes da Coorte de Universidades Mineiras (Estudo CUME). Métodos: Inicialmente, foi realizada uma revisão integrativa da literatura e, em seguida, dois estudos de coorte prospectiva. A) Artigo 1 ­ revisão integrativa da literatura sobre a estimação do alto risco cardiovascular e seus fatores associados, realizada nas bases Medical Literature Analysis and Retrievel System Online, Web of Science, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature e no portal Biblioteca Virtual de Saúde; B) Artigo 2 ­ Coorte aberta prospectiva desenvolvida com 2.854 participantes do Estudo CUME, que é uma pesquisa multicêntrica conduzida com egressos de sete instituições públicas federais de ensino superior do Estado de Minas Gerais desde 2016. A incidência do alto risco cardiovascular de 30 anos foi calculada usando o escore de Framingham e seus determinantes foram estimados usando análise multivariada hierárquica pela técnica de regressão de Cox; C) Artigo 3 ­ Estudo prospectivo fechado desenvolvido com 1.286 participantes da CUME, que responderam ao questionário da linha de base em 2016, aos questionários de seguimento de dois anos (2018) e de quatro anos (2020). O risco cardiovascular foi avaliado com o escore de Framingham de 30 anos. A identificação das trajetórias do risco cardiovascular foi realizada com a técnica de modelagem de crescimento de classe latente com o uso do modelo normal censurado. A análise dos fatores independentemente associados a cada uma das trajetórias foi conduzida com a técnica de regressão logística multinominal. Resultados: Artigo 1 ­ foram selecionados 13 artigos com um ou mais fatores associados ao alto risco cardiovascular, segundo o escore de Framingham de 10 anos. Nenhum artigo investigou os fatores associados ao alto risco cardiovascular de 30 anos. Artigo 2 ­ após média de 2,62 anos de seguimento, a incidência do alto risco cardiovascular de 30 anos foi 8,1 casos/1.000 pessoas-ano no sexo feminino e 20,2 casos/1.000 pessoas-ano no sexo masculino. Sexo masculino (Hazard Ratio ­ HR: 2,34; IC 95%: 1,58 - 3,46), trabalhar (HR: 2,13; IC 95%: 1,13 - 3,99), alto consumo de alimentos processados (HR: 2,44; 95% CI: 1,21 - 4,90) e ser ativo fisicamente (HR: 0,63; IC 95%: 0,41 - 0,98) se associaram independentemente ao alto risco cardiovascular de 30 anos; Artigo 3 - Três trajetórias de risco cardiovascular de 30 anos foram identificadas: Baixo-Baixo (68,3%), Médio-Médio (26,2%) e Alto-Alto (5,5%). Ao longo do tempo, o risco cardiovascular apresentou discreto aumento para a trajetória Baixo-Baixo (2,9%), moderado aumento para a trajetória Médio-Médio (7,6%) e elevado aumento para a trajetória Alto-Alto (13%). O sexo masculino, viver em união estável, ter consumos moderado e alto de alimentos ultraprocessados se associaram positivamente às trajetórias de risco cardiovascular Médio-Médio e Alto-Alto. Ainda, ter formação profissional fora da área da saúde e estar trabalhando se associaram positivamente à trajetória de risco cardiovascular Médio-Médio, enquanto ser ativo fisicamente se associou negativamente à trajetória de risco cardiovascular Alto-Alto. Conclusão: Poucos estudos foram conduzidos para avaliar o alto risco cardiovascular de 30 anos, sendo que em nenhum deles foram estimados fatores associados ao desfecho. Nossos achados científicos indicaram que praticar atividade física reduz a incidência do alto risco cardiovascular de 30 anos. Homens, pessoas que trabalham e com consumo elevado de alimentos processados devem ser monitorados com maior cautela, pois apresentaram maior susceptibilidade de ocorrência do alto risco cardiovascular de 30 anos. Adultos jovens e com melhor situação socioeconômica possuem uma trajetória de baixo risco cardiovascular de 30 anos, entretanto, há uma tendência de piora desta trajetória ao longo do tempo devido aos maus hábitos de vida. Dessa forma, é essencial a implementação de estratégias de prevenção para evitar o adoecimento cardiovascular.

Introduction: Cardiovascular diseases are the main public health problem worldwide. Therefore, the assessment of cardiovascular risk, with the identification of its risk and protection factors and their trajectories over time, are important for proposing, consolidating and implementing measures to prevent the occurrence of cardiovascular diseases. General objective: To analyze the 30-year trajectory and determinants of high cardiovascular risk in participants of the Cohort of Universities of Minas Gerais (CUME Study). Methods: Initially, an integrative literature review was performed, followed by two prospective cohort studies. A) Article 1 ­ integrative review of the literature on the estimation of high cardiovascular risk and its associated factors, carried out in the databases Medical Literature Analysis and Retrievel System Online, Web of Science, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature and the Virtual Health Library portal; B) Article 2 ­ Prospective open cohort developed with 2,854 participants of the CUME Study, which is a multicenter research conducted with graduates from seven federal public institutions of higher education in the State of Minas Gerais since 2016. The incidence of high cardiovascular risk at 30 years was calculated using the Framingham score and its determinants were estimated using hierarchical multivariate analysis by the Cox regression technique; C) Article 3 ­ Prospective closed study developed with 1,286 participants from CUME, who answered the baseline questionnaire in 2016, the two-year follow-up questionnaire in 2018 and the four-year follow-up questionnaire in 2020. The risk Cardiovascular was assessed using the 30-year Framingham score. The identification of cardiovascular risk trajectories was performed using the latent class growth modeling technique using the normal censored model. The analysis of the factors independently associated with each of the trajectories was conducted using the multinomial logistic regression technique. Results: Article 1 ­ 13 articles were selected with one or more factors associated with high cardiovascular risk, according to the Framingham score over 10 years. No article investigated the factors associated with 30-year high cardiovascular risk. Article 2 ­ After an average of 2.62 years of follow-up, the incidence of high cardiovascular risk at 30 years was 8.1 cases/1,000 person-years in females and 20.2 cases/1,000 person-years in males. Male sex (Hazard Ratio ­ HR: 2.34; 95% CI: 1.58 - 3.46), work (HR: 2.13; 95% CI: 1.13 - 3.99), high food intake processed foods (HR: 2.44; 95% CI: 1.21 - 4.90) and being physically active (HR: 0.63; 95% CI: 0.41 - 0.98) were independently associated with high cardiovascular risk 30 years old; Article 3 - Three 30-year cardiovascular risk trajectories were identified: Low-Low (68.3%), Medium-Medium (26.2%) and High-High (5.5%). Over time, cardiovascular risk showed a slight increase for the Low-Low trajectory (2.9%), a moderate increase for the Medium-Medium trajectory (7.6%) and a high increase for the High-High trajectory (13%). Being male, living in a stable relationship, having moderate and high consumption of ultra-processed foods were positively associated with Medium-Medium and High-High cardiovascular risk trajectories. Also, having professional training outside the health area and being working were positively associated with the Medium-Medium cardiovascular risk trajectory, while being physically active was negatively associated with the High-High cardiovascular risk trajectory. Conclusion: Few studies were conducted to assess the 30-year high cardiovascular risk, and none of them estimated factors associated with the outcome. Our scientific findings indicated that practicing physical activity reduces the incidence of 30-year high cardiovascular risk. Men, people who work and with a high consumption of processed foods should be monitored with greater caution, as they were more susceptible to the occurrence of the high cardiovascular risk of 30 years. Young adults with better socioeconomic status have a 30-year trajectory of low cardiovascular risk, however, there is a tendency for this trajectory to worsen over time due to bad lifestyle habits. Thus, it is essential to implement prevention strategies to avoid cardiovascular disease.

Sobrevida de los recién nacidos con cardiopatías congénitas diagnosticadas prenatalmente / Survival of newborns with prenatally diagnosed congenital heart disease

Objetivo: Estimar la sobrevida al año de los recién nacidos con cardiopatías congénitas diagnosticadas prenatalmente y el perfil epidemiológico de sus madres. Método: Cohorte dinámica retrospectiva de 825 pacientes, ingresados entre el 1 de abril de 2003 y el 31 de marzo de 2019, con tiempo de seguimiento de 1 año, que se elaboró utilizando la base de datos del Centro de Referencia Perinatal Oriente (CERPO), Facultad de Medicina, Universidad de Chile. Resultados: Se estimó la función de supervivencia global de la muestra, obteniendo una supervivencia del 70% al año de seguimiento (error estándar (ES): 0,0164; intervalo de confianza del 95% [IC95%]: 0,66-0,73). Los recién nacidos con edad gestacional < 30 semanas tuvieron una menor sobrevida (hazard ratio [HR]: 4,17; IC95%: 1,52-11.44; p < 0,01). Los recién nacidos con un peso < 3000 g tuvieron una menor sobrevida (HR: 1,41; IC95%: 1,09-1,84; p < 0,01). La distribución de las cardiopatías congénitas según la gravedad en esta cohorte fue: riesgo vital 64%, clínicamente relevante 34% y clínicamente no relevante 2%. La menor sobrevida fue para la categoría riesgo vital (HR: 6,005; IC95%: 3,97-9,08; p < 0,01). Conclusiones: La prematuridad, el bajo peso al nacer y la gravedad de la cardiopatía se correlacionaron con una menor sobrevida.

Objective: To estimate the survival at one year of newborns with prenatally diagnosed congenital heart diseases and the epidemiological profile of their mothers. Method: Dynamic retrospective cohort of 825 patients, admitted between April 1, 2003 and March 31, 2019, with a follow-up time of 1 year, which was elaborated using the database of the Centro de Referencia Perinatal Oriente (CERPO), Faculty of Medicine, Universidad de Chile. Results: The overall survival function of the sample was estimated, resulting in a survival of 70% at one year follow-up (standard error (SE): 0.0164; 95% confidence interval [95% CI]: 0.66-0.73). Newborns with gestational age < 30 weeks had a lower survival (hazard ratio [HR]: 4.17; 95% CI: 1.52-11.44; p < 0.01). Newborns with a birth weight < 3000 g had a lower survival (HR: 1.41; 95% CI: 1.09-1.84; p < 0.01). The distribution of congenital heart disease according to severity in this cohort was: life-threatening 64%, clinically relevant 34% and clinically not relevant 2%. With a lower survival for the life-threatening category (HR: 6.005; 95% CI: 3.97-9.08; p < 0.01). Conclusions: Prematurity, low birth weight and severity of congenital heart correlated with a lower survival rate.

Efeitos do Ato de Fumar na Mortalidade de Longo Prazo após Infarto do Miocárdio por Elevação de ST / Effects of Smoking on Very-Long Term Mortality after First ST Elevation Myocardial Infarction

Resumo Fundamento O paradoxo do fumante tem sido motivo de debate para pacientes com infarto agudo do miocárdio (IM) há mais de duas décadas. Embora haja muitas evidências demonstrando que não existe tal paradoxo, publicações defendendo desfechos melhores em fumantes pós-IM ainda são lançadas. Objetivo Explorar o efeito do fumo na mortalidade de longo prazo após infarto do miocárdio por elevação de ST (STEMI). Métodos Este estudo incluiu pacientes com STEMI que foram diagnosticados entre 2004 e 2006 em três centros terciários. Os pacientes foram categorizados de acordo com a exposição ao tabaco (Grupo 1: não-fumantes; Grupo 2: <20 pacotes*anos; Grupo 3: 2-040 pacotes*anos; Grupo 4: >40 pacotes*anos). Um modelo de regressão de Cox foi utilizado para estimar os riscos relativos para mortalidade de longo prazo. O valor de p <0,05 foi considerado como estatisticamente significativo. Resultados Trezentos e treze pacientes (201 fumantes e 112 não-fumantes) foram acompanhados por um período médio de 174 meses. Os fumantes eram mais novos (54±9 vs. 62±11, p: <0,001), e a presença de fatores de risco cardiometabólicos foi mais prevalente entre os não-fumantes. Uma análise univariada do impacto do hábito de fumar na mortalidade revelou uma curva de sobrevivência melhor no Grupo 2 do que no Grupo 1. Porém, após ajustes para fatores de confusão, observou-se que os fumantes tinham um risco de morte significativamente maior. O risco relativo tornou-se maior de acordo com a maior exposição (Grupo 2 vs. Grupo 1: RR: 1,141; IC95%: 0,599 a 2.171; Grupo 3 vs. Grupo 1: RR: 2,130; IC95%: 1,236 a 3,670; Grupo 4 vs. Grupo 1: RR: 2,602; IC95%: 1,461 a 4,634). Conclusão O hábito de fumar gradualmente aumenta o risco de mortalidade por todas as causas após STEMI.

Abstract Background The smoking paradox has been a matter of debate for acute myocardial infarction patients for more than two decades. Although there is huge evidence claiming that is no real paradox, publications supporting better outcomes in post-MI smokers are still being released. Objective To explore the effect of smoking on very long-term mortality after ST Elevation myocardial infarction (STEMI). Methods This study included STEMI patients who were diagnosed between the years of 2004-2006 at three tertiary centers. Patients were categorized according to tobacco exposure (Group 1: non-smokers; Group 2: <20 package*years users, Group 3: 20-40 package*years users, Group 4: >40 package*years users). A Cox regression model was used to estimate the relative risks for very long-term mortality. P value <0.05 was considered as statistically significant. Results There were 313 patients (201 smokers, 112 non-smokers) who were followed-up for a median period of 174 months. Smokers were younger (54±9 vs. 62±11, p: <0.001), and the presence of cardiometabolic risk factors were more prevalent in non-smokers. A univariate analysis of the impact of the smoking habit on mortality revealed a better survival curve in Group 2 than in Group 1. However, after adjustment for confounders, it was observed that smokers had a significantly increased risk of death. The relative risk became higher with increased exposure (Group 2 vs. Group 1; HR: 1.141; 95% CI: 0.599 to 2.171, Group 3 vs Group 1; HR: 2.130; 95% CI: 1.236 to 3.670, Group 4 vs Group 1; HR: 2.602; 95% CI: 1.461 to 4.634). Conclusion Smoking gradually increases the risk of all-cause mortality after STEMI.

Biochemical Relapse in Low-risk Prostate Cancer Treated with Radical Prostatectomy and Bilateral Pelvic Lymphadenectomy / Recaída bioquímica en cáncer de próstata de bajo riesgo tratado con prostatectomía radical y linfadenectomía pélvica bilateral

Introduction For low-risk prostate cancer (PCa), curative treatment with radical prostatectomy (RP) can be performed, reporting a biochemical relapse-free survival rate (bRFS) at 5 and 7 years of 90.1% and 88.3%, respectively. Prostatic specific antigen (PSA), pathological stage (pT), and positive margins (R1) are significant predictors of biochemical relapse (BR). Even though pelvic lymphadenectomy is not recommended during RP, in the literature, it is performed in 34% of these patients, finding 0.37% of positive lymph nodes (N1). In this study, we aim to evaluate the 10-year bRFS in patients with low-risk PCa who underwent RP and extended pelvic lymph node dissection (ePLND). Methodology All low-risk patients who underwent RP plus bilateral ePLND at the National Cancer Institute of Colombia between 2006 and 2019 were reviewed. Biochemical relapse was defined as 2 consecutive increasing levels of PSA > 0.2 ng/mL. A descriptive analysis was performed using the STATA 15 software (Stata Corp., College Station, TX, USA), and the Kaplan-Meier curves and uni and multivariate Cox proportional hazard models were used for the survival outcome analysis. The related regression coefficients were used for the hazard ratio (HR), and, for all comparisons, a two-sided p-value ˂ 0.05 was used to define statistical significance. Results Two hundred and two patients met the study criteria. The 10-year bRFS for the general population was 82.5%, statistically related to stage pT3 (p = 0.047), higher Gleason grade group (GG) (p ≤ 0.001), and R1 (p ≤ 0.001), but not with N1. A total of 3.9% of the patients had N1; of these, 75% had R1, 25% GG2, and 37% GG3. Among the N0 (non-lymph node metástasis in prostate cáncer) patients, 31% of the patients had R1, 41% GG2, and 13% GG3. Conclusions Our bRFS was 82.5% in low-risk patients who underwent RP and ePLND. With higher pT, GG, and presence of R1, the probability of BR increased. Those with pN1 (pathologicaly confirmed positive lymph nodes) were not associated with bRFS, with a pN1 detection rate of 3.9%. Details: In low-risk PCa, curative treatment with RP can be performed, reporting a bRFS rate at 5 and 7 years of 90.1% and 88.3%, respectively. Despite the fact that pelvic lymphadenectomy is not recommended during RP in clinical guidelines, in the literature, it is performed in 34% of these patients, finding 0.37% of N1. In this study, we report the 10-year bRFS in patients with low-risk PCa who underwent surgery.

Introducción En el cáncer de próstata (CaP) de bajo riesgo se puede realizar un tratamiento curativo mediante prostatectomía radical (PR), con una tasa de supervivencia libre de recaída bioquímica (SLRb) a 5 y 7 años del 90,1% y el 88,3%, respectivamente. El antígeno prostático específico (PSA), el estadio patológico (pT) y los márgenes positivos (R1) son predictores significativos de recaída bioquímica (BR). Aunque la linfadenectomía pélvica no está recomendada durante la PR, en la literatura se realiza en el 34% de estos pacientes, encontrándose un 0,37% de ganglios linfáticos positivos (N1). En este estudio, nuestro objetivo es evaluar la SLB a 10 años en pacientes con CaP de bajo riesgo sometidos a PR y disección ganglionar pélvica extendida (DGLPe). Metodología Se revisaron todos los pacientes de bajo riesgo sometidos a PR más ePLND bilateral en el Instituto Nacional de Cancerología de Colombia entre 2006 y 2019. La recaída bioquímica se definió como 2 niveles crecientes consecutivos de PSA > 0,2 ng/mL. Se realizó un análisis descriptivo utilizando el software STATA 15 (Stata Corp., College Station, TX, USA), y se utilizaron las curvas de Kaplan-Meier y los modelos uni y multivariados de riesgos proporcionales de Cox para el análisis de resultados de supervivencia. Los coeficientes de regresión relacionados se utilizaron para la hazard ratio (HR), y, para todas las comparaciones, se utilizó un valor p de dos caras ˂ 0,05 para definir la significación estadística. Resultados Doscientos dos pacientes cumplieron los criterios del estudio. La bRFS a 10 años para la población general fue del 82,5%, estadísticamente relacionada con el estadio pT3 (p = 0,047), mayor grupo de grado Gleason (GG) (p ≤ 0,001), y R1 (p ≤ 0,001), pero no con N1. Un total del 3,9% de los pacientes tenían N1; de ellos, el 75% tenían R1, el 25% GG2, y el 37% GG3. Entre los pacientes N0 (metástasis no ganglionar en el cáncer de próstata), el 31% de los pacientes tenían R1, el 41% GG2 y el 13% GG3. Conclusiones Nuestra SSEb fue del 82,5% en los pacientes de bajo riesgo que se sometieron a RP y ePLND. A mayor pT, GG y presencia de R1, mayor probabilidad de RB. Aquellos con pN1 (ganglios linfáticos patológicamente confirmados como positivos) no se asociaron con la SSEb, con una tasa de detección de pN1 del 3,9%. Detalles: En el CaP de bajo riesgo se puede realizar tratamiento curativo con PR, reportando una tasa de SSEb a 5 y 7 años de 90,1% y 88,3%, respectivamente. A pesar de que la linfadenectomía pélvica no está recomendada durante la PR en las guías clínicas, en la literatura se realiza en el 34% de estos pacientes, encontrando un 0,37% de N1. En este estudio, reportamos la SLB a 10 años en pacientes con CaP de bajo riesgo sometidos a cirugía.

Periodontal disease and the risk of prostate cancer: a meta-analysis of cohort studies

ABSTRACT Background: Periodontal disease is reportedly associated with the risk of various systemic diseases, including pancreatic and lung cancers. However, its association with prostate cancer remains inconclusive. Herein, we explored the association of periodontal disease with the risk of prostate cancer through a meta-analysis. Materials and Methods: MEDLINE, Embase, Web of Sciences and Cochrane Library databases were searched for eligible publications up to April 2020. Multivariate adjusted risk estimates with corresponding 95% confidence intervals (CIs) were extracted and calculated using random- or fixed-effect models. Results: Nine cohort studies involving 3.353 prostate cancer cases with 440.911 participants were identified and included in the meta-analysis. We found that periodontal disease significantly increased the risk of prostate cancer by 1.40-fold (hazard ratio [HR]=1.40, 95% CI: 1.16-1.70; P=0.001; I2=76.1%) compared with normal condition. Interestingly, the risk of developing prostate cancer was not significant in patients treated with periodontal therapy (HR=1.22, 95% CI: 0.86-1.73; P=0.272; I2=65.2%). The results of subgroup analyses were also consistent and significant when stratified by study design and follow-up period, whereas conflicting results were observed in periodontal disease ascertainment stratification. These findings were robust as indicated by sensitivity analyses. Conclusions: Periodontal disease was associated with the increased risk of prostate cancer, whereas no significant association was observed in patients treated with periodontal therapy. Hence, the awareness and importance for maintaining oral health should be improved, and the underlying mechanisms linking periodontal disease and prostate cancer should be fully explored in future research.

Valor predictivo prequirúrgico del EuroSCORE I, EuroSCORE II y STS score en pacientes sometidos a cirugía cardíaca: informe preliminar / Pre-surgical predictive value of the EuroSCORE I, EuroSCORE II and STS score in patients undergoing cardiac surgery: preliminary report

RESUMEN Introducción: en cirugía cardiovascular, el EuroSCORE I, EuroSCORE II y STS score son herramientas que brindan pronóstico e información para la toma de decisiones. Es imperativo evaluar el valor predictivo real de los mismos en nuestro medio. Objetivo: evaluar el valor predictivo de los citados scores en pacientes sometidos a cirugía cardíaca en el área de cardiología del Hospital Nacional. Metodología: estudio de cohortes, retrospectivo, con muestreo no probabilístico de casos consecutivos. La población estuvo constituida por pacientes sometidos a cirugía cardiaca en el periodo comprendido entre enero 2020 a julio 2021. Fueron evaluadas 60 historias clínicas, excluidas 6, quedando finalmente 54 expedientes. Resultado: predominó el sexo masculino 57,14 %, la edad media fue de 60 ± 12 años (rango 26 - 82 años). El EuroSCORE II presentó un riesgo relativo de 10 (IC 95 % 1,3 ­ 90), p=0,004, sensibilidad 80 %, especificidad 78,43 %, VPP 26,67 % (IC 95 % 0,95 a 52,38) y VPN 97,56 % (IC 95 % 91,62 a 100 %). El EuroSCORE I presentó riesgo relativo de 1,6 (IC 95 % 0,2 ­ 10,9) p=0,50, sensibilidad 60 %, especificidad 52,94 %, VPP 11,11 % (IC 95 % 0,00 a 24,82) y VPN 93,10 % (IC 95 % 82,16 a 100 %). El STS score arrojó un riesgo relativo de 3,5 (IC 95 % 0,07 ­ 35), p=0,10, sensibilidad del 20 %, especificidad 93,33 %, valor predictivo positivo del 25 % (IC 95 % 0,00 a 79,93) y valor predictivo negativo 91,30 % (IC 95 % 82,07 a 100 %). La mortalidad global fue 8,93 % y morbilidad 93 %. Conclusión: se demostró un alto valor predictivo negativo en los scores, lo que determinó que pacientes con riesgo bajo e intermedio tuvieran una mortalidad baja.

ABSTRACT Introduction: in cardiovascular surgery, the EuroSCORE I, EuroSCORE II and STS score are tools that provide prognosis and information for decision making. It is imperative to evaluate their real predictive value in our environment. Objective: to evaluate the predictive value of the aforementioned scores in patients undergoing cardiac surgery in the Hospital Nacional cardiology area. Methodology: retrospective cohort study, with non-probabilistic sampling of consecutive cases. The population consisted of patients undergoing cardiac surgery in the period from January 2020 to July 2021. 60 medical records were evaluated, 6 excluded, finally leaving 54 records. Result: male sex predominated 57,14 %, the mean age was 60 ± 12 years (range 26 - 82 years old). The EuroSCORE II presented a relative risk of 10 (95 % CI 1.3 - 90), p = 0.004, sensitivity 80 %, specificity 78,43 %, PPV 26,67 % (95 % CI 0,95 to 52,38) and NPV 97,56 % (95 % CI 91,62 to 100 %). The EuroSCORE I presented a relative risk of 1.6 (95 % CI 0.2 - 10.9) p = 0.50, sensitivity 60 %, specificity 52,94 %, PPV 11,11 % (95 % CI 0.00 a 24,82) and NPV 93,10 % (95 % CI 82.16 to 100 %). The STS score yielded a relative risk of 3,5 (95 % CI 0.07 - 35), p = 0.10, sensitivity of 20 %, specificity 93,33 %, positive predictive value of 25 % (CI 95 % 0 .00 to 79.93) and negative predictive value 91,30 % (95 % CI 82.07 to 100 %). Overall mortality was 8,93 % and morbidity 93 %. Conclusion: a high negative predictive value was demonstrated in the scores, which determined that patients with low and intermediate risk had a low mortality.

O prognóstico da doença arterial coronariana em um Hospital Público no Brasil: Achado do estudo ERICO / The prognosis of coronary artery disease in a brazilian community hospital: Findings from the ERICO study

Resumo Fundamento O prognóstico de longo prazo pós síndrome coronária aguda (SCA) no cuidado secundário não é bem conhecido. A gravidade da doença arterial coronariana (DAC) como preditor de mortalidade no longo prazo foi avaliada em um hospital público no Brasil. Objetivo O objetivo deste estudo foi comparar o prognóstico de curto e longo prazo após um evento de SCA, de acordo com a gravidade da doença obstrutiva, em pacientes atendidos em um hospital público secundário para um coorte prospectivo sobre DAC no Brasil (o Estudo de Registro de Insuficiência Coronariana, estudo ERICO) Métodos Foram realizadas análises de sobrevida por curvas de Kaplan-Meier e modelo de risco proporcional de Cox [razão de risco (RR) com o respectivo intervalo de confiança (IC) de 95% para avaliar mortalidade cumulativa global, por DCV e DAC, de acordo com a obstrução arterial coronária: sem obstrução (grupo de referência), doença de um vaso, doença de dois vasos, doença de múltiplos vasos] entre 800 adultos do estudo ERICO durante 4 anos de monitoramento. As RR são apresentadas como dados brutos e posteriormente padronizadas quanto a possíveis fatores de confusão, no período de 180 dias até 4 anos de monitoramento após a SCA. O p-valor <0.05 foi considerado estatisticamente significativo. Resultados Taxas de sobrevida mais baixas foram detectadas entre indivíduos com a doença de múltiplos vasos (global, DCV e DAC, p de teste de Log-rank <0,0001). Depois da padronização multivariada, a doença de múltiplos vasos [RR; 2,33 (IC 95%; 1,10-4,95)] e doença de um vaso obstruído [RR; 2,44 (IC 95%; 1,11-5,34)] tiveram o risco mais alto de mortalidade global comparadas aos índices dos sujeitos sem obstrução no monitoramento de 4 anos. Conclusões Não só os pacientes com doença de múltiplos vasos como também os com doença de um vaso tiveram alto risco de mortalidade no longo prazo pós-SCA. Esses achados destacam a importância de se ter uma abordagem melhor no tratamento e no controle de fatores de risco cardiovascular, mesmo em indivíduos com risco aparentemente baixo, atendidos em cuidado secundário.

Abstract Background Long-term prognosis post-acute coronary syndrome (ACS) in secondary care is not well-known. The severity of coronary artery disease (CAD) as a predictor of long-term mortality was evaluated in a community hospital in Brazil. Objective We aimed to compare short and long-term prognosis after an ACS event according to severity of obstructive disease in patients attended in a secondary community hospital from prospective CAD cohort in Brazil (the Strategy of Registry of Acute Coronary Syndrome, ERICO study). Methods Survival analyses were performed by Kaplan-Meier curves and Cox proportional hazard models (hazard ratios (HR) with respective 95% confidence interval (CI) to evaluate cumulative all-cause, CVD and CAD mortality according the coronary artery obstruction: no-obstruction (reference group), 1-vessel-disease, 2-vessel-disease, multivessel-disease) among 800 adults from an ERICO study during a 4-year-follow-up. HR are presented as crude and further adjusted for potential confounders from 180 days to 4-year follow-up after ACS. A p-value <0.05 was considered statistically significant. Results Poorer survival rates were detected among individuals with multivessel-disease (all-cause, CVD and CAD, p-log rank< 0.0001). After multivariate adjustments, multivessel-disease -(HR; 2.33 (CI 95%; 1.10-4.95)) and 1-vessel-disease obstructed (HR; 2.44 (CI 95%; 1.11-5.34)) had the highest risk for all-cause mortality compared to those with no obstruction at 4-year follow-up. Conclusions Not only multivessel-disease, but also 1-vessel-disease patients showed a high long-term mortality risk post-ACS. These findings highlight the importance of having a better approach in the treatment and control of cardiovascular risk even in apparently low-risk individuals attended to in secondary care.

Evaluación y comparación del desempeño de cinco modelos de predicción de mortalidad intrahospitalaria en pacientes con falla cardiaca aguda / Evaluation and comparison of the performance of five prediction models of in-hospital mortality in patients with acute heart failure

Resumen Objetivo: Los modelos de predicción de mortalidad intrahospitalaria en pacientes con falla cardiaca aguda pueden ser útiles para la toma de decisiones, situación que hace necesario evaluar la capacidad predictiva y de discriminación en la población colombiana. Método: Estudio de cohorte retrospectiva de pacientes con falla cardiaca aguda. Se evaluó el desempeño de los modelos de predicción de mortalidad intrahospitalaria ADHERE, OPTIMIZE-HF, GWTG-HF y PROTECT, durante los años 2013 a 2015. Se realizó el cálculo de la puntuación para cada uno de los modelos y se determinó la capacidad de predicción y discriminación. Resultados: Se incluyeron 776 pacientes con una edad promedio de 71.5 años (desviación estándar: 14.3), el 56% hombres, con fracción de eyección del ventrículo izquierdo del 39%. La mortalidad global fue del 6.1%. El área bajo la curva para ADHERE fue de 0.56 (intervalo de confianza del 95% [IC95%]: 0.49-0.64), para EHMRG de 0.63 (IC95%: 0.55-0.71], para GWTG-HF de 0.63 (IC95%: 0.55-0.70), para OPTIMIZE de 0.65 (IC95%: 0.56-0.74) y para PROTECT de 0.69 (IC95%: 0.60-0.77). Conclusiones: Los modelos de predicción de muerte intrahospitalaria en pacientes con falla cardiaca aguda muestran pobre desempeño y baja capacidad de predicción y discriminación en población colombiana, lo cual sugiere el desarrollo de escalas de predicción de mortalidad en pacientes con falla cardiaca aguda específicas para dicha población.

Abstract Objective: In-hospital mortality prediction models on acute heart failure can be beneficial for decision-making, a situation necessary to evaluate, our goal was to compare predictive and discriminatory capacity of Colombian population. Method: A retrospective cohort study in patients with acute heart failure was conducted. The following performance evaluation of in-hospital mortality prediction models were conducted from 2013 to 2015: ADHERE, EHMRG, OPTIMIZE-HF, GWTG-HF and PROTECT. Data was calculated for each model, prediction and discriminatory capacity was evaluated. Results: A sample of 776 patients, 56% male, with an average age of 71.5 (standard deviation: 14.3) and with left ventricle ejection fraction rate of 39% was studied. Global mortality was of 6.1%. The area under curve for ADHERE was of 0.56 (95% confidence interval [95% CI]: 0.49-0.64), for EHMRG 0.63 (95% CI: 0.55-0.71), for GWTG-HF 0.63 (95% CI: 0.55-0.70), for OPTIMIZE 0.65 (95% CI: 0.56-0.74) and for PROTECT 0.69 (95% CI: 0.60-0.77). Conclusions: The models for predicting in-hospital death in patients with acute heart failure show poor performance, predictability and discrimination in the Colombian population, suggesting the development of mortality prediction scales in patients with acute heart failure specific to our population.

Geriatric nutritional risk index predicts all-cause mortality in patients with heart failure: A systematic review and meta-analysis

OBJECTIVES: Geriatric nutritional risk index (GNRI) might predict the all-cause mortality in patients with heart failure (HF). We performed a meta-analysis to evaluate the correlation between GNRI and all-cause mortality in patients with HF. METHODS: We searched the PubMed, Medline, Cochrane Library, and Embase databases for clinical trials investigating the association between GNRI and all-cause mortality in patients with HF, having the primary endpoint as all-cause mortality. RESULTS: In total, nine studies involving 7,659 subjects were included in the systematic review and meta-analysis. The results indicated that major risk and moderate risk GNRI (GNRI<92) was associated with an increased risk of all-cause mortality in elderly patients with HF (hazard ratios [HR] 1.59, 95% confidence intervals [CI] 1.37-1.85). Low risk GNRI (GNRI<98) group predicted all-cause mortality in elderly HF patients (HR 1.56, 95%CI 1.12-2.18) when compared with the high GNRI value group. A subgroup analysis indicated that the relationship between GNRI and HF might differ based on the subtype of heart failure. CONCLUSIONS: GNRI is a simple and well-established nutritional assessment tool to predict all-cause mortality in patients with HF.

Predictive risk model of livestock rabies occurrence in Peru / Modelo de risco preditivo para a ocorrência da raiva bovina no Peru

Livestock rabies is endemic in Peru. Hence, its persistence and annual dissemination represent an important economic impact, especially for impoverished farming communities. The disease is mostly transmitted by the hematophagous bat Desmodus rotundus. The present study aimed to adapt an existing predictive model of the occurrence of livestock rabies to Peru, in which the risk of rabies transmission from bats to livestock was estimated using decision-tree models of receptivity and vulnerability. Official rabies surveillance data between 2010 and 2015 were used along with possible risk factors, such as livestock biomass, environmental changes, and geomorphological characteristics. Several scenarios were established to evaluate the prediction of the occurrence of livestock rabies cases by determining more than one cut-off point of the receptivity variables. During the study period, the precision of the model was estimated through the sensitivity (39.46%) and specificity (98.64%) by using confusion matrices. Targeting control efforts, especially in districts with a high estimated risk, could represent the prevention of a significant proportion of livestock rabies cases, which would optimize the human and economic resources of the Peruvian surveillance service. However, the quality of data produced by the surveillance should be improved not only to obtain higher model precision but also to allow the adequate planning of control actions.(AU)

Raiva de herbívoros é endêmica no Peru. Consequentemente, sua disseminação persistente e anual representa um importante impacto econômico, especialmente às comunidades rurais empobrecidas. A doença é principalmente transmitida pelo morcego hematófago Desmodus rotundus. Este estudo tem por objetivo adaptar um modelo preditivo pré-existente às ocorrências de raiva de herbívoros no Peru, no qual o risco de transmissão de morcegos para os herbívoros foi estimado por meio de árvores de cenários de receptividade e vulnerabilidade. Foram usados os dados oficiais de vigilância da raiva entre 2010 e 2015, assim como os possíveis fatores de risco, tais quais a biomassa de animais, alterações ambientais e características geomorfológicas. Diversos cenários foram criados para avaliar a predição da ocorrência da raiva por meio da determinação de diversos pontos de corte das variáveis de receptividade. Durante o período de estudo, a precisão do modelo foi estimada por meio da sensibilidade (39,46%) e especificidade (98,64%), utilizando matrizes de confusão. Focando em esforços de controle, especialmente em distritos com elevado risco estimado, seria possível prevenir uma proporção significativa dos focos, o que poderia otimizar os recursos humanos e econômicos do serviço oficial peruano. Entretanto, a qualidade dos dados produzidos pelo sistema de vigilância deveria ser melhorada não somente para obter maior precisão do modelo, mas também para possibilitar o melhor planejamento das ações de controle desta doença.(AU)

Fatores associados ao tempo de ocorrência das reações hansênicas numa coorte de 2008 a 2016 em Rondônia, Região Amazônica, Brasil / Factors associated with timing of lepra reactions in a cohort from 2008 to 2016 in Rondônia, Amazon Region, Brazil / Factores asociados al tiempo de ocurrencia de las reacciones hansénicas en una cohorte de 2008 a 2016 en Rondonia, Región Amazónica, Brasil

O manejo clínico de pacientes com hanseníase apresenta um desafio particular que são as reações. O objetivo deste estudo de coorte não concorrente foi analisar o tempo e fatores associados à ocorrência da primeira reação durante e após o tratamento da poliquimioterapia (PQT). Avaliou-se 1.621 pacientes paucibacilares (PB = 8,9%) e multibacilares (MB = 91,1%) de 2008 a 2016 notificados no Sistema de Estados Reacionais em Hanseníase/Rondônia (SisReação/RO). Prevaleceu a ocorrência durante o tratamento da PQT = 997 (61,5%), e 624 (38,5%) somente após o PQT. A precocidade da reação, a partir do diagnóstico, foi analisada por meio de curvas de sobrevida de Kaplan-Meier e comparadas entre os grupos PB e MB, usando o teste de log-rank de Mantel-Cox; e foram construídos modelos de regressão de Cox univariada e multivariada para identificar os fatores associados à ocorrência da reação (hazard ratio) e os correspondentes IC95%. No modelo multivariado foram incluídas variáveis com valores de p < 0,2 na análise univariada. Os PB desenvolveram reação de forma mais precoce do que os MB. Outras características associaram-se à reação em menor tempo: sexo feminino e baciloscopia negativa. No período agregado (durante e após a PQT), os pacientes PB apresentaram risco 24% maior de reação do que os MB e aqueles com baciloscopia negativa aumentaram este risco em 40% comparado à baciloscopia positiva. Durante e após a PQT, os PB apresentaram 1,3 e 1,6 vezes maior risco de ocorrência da reação dos pacientes MB. Dessa forma, recomendamos priorizar ações de vigilância para reações hansênicas durante e após a PQT como medidas de prevenção de incapacidades físicas e de melhoria na qualidade de vida das pessoas acometidas pela hanseníase.

The clinical management of leprosy patients poses a specific challenge, namely lepra reactions. This non-concurrent cohort study aimed to analyze the timing of the first lepra reaction during and after polychemotherapy (PCT) and associated factors. A total of 1,621 patients were assessed (PB = 8.9% and MB = 91.1%) from 2008 to 2016, reported to the System of Reaction States in Leprosy (SisReação/RO) database. Reactions occurred predominantly during PCT (997; 61.5%) and less frequently only after PCT (624; 38.5%). Earliness of the reaction after diagnosis was analyzed with Kaplan-Meier survival curves, with comparison between the PB and MB groups using the Mantel-Cox log-rank test. Univariate and multivariate Cox regression models were constructed to identify factors associated with occurrence of lepra reactions (hazard ratio) and the corresponding 95%CI. The multivariate model included variables with p-values < 0.20 in the univariate analysis. PB patients developed reactions earlier than MB patients. Other characteristics were associated with earlier reactions: female gender and negative smear microscopy. In the aggregate period (during and after PCT), PB presented 24% higher risk of lepra reaction than MB patients, and negative smear microscopy increased this risk by 40% compared to positive smear microscopy. During and after PCT, PB presented 1.3 and 1.6 times the risk, respectively, of reactions when compared to MB patients. We thus recommend prioritizing surveillance of lepra reactions during and after PCT as measures to prevent physical disabilities and to improve quality of life for persons with leprosy.

La gestión clínica de pacientes con hanseniasis presenta un desafío particular que son las reacciones. El objetivo de este estudio de cohorte no concurrente fue analizar el tiempo y factores asociados a la ocurrencia de la primera reacción durante y tras el tratamiento de la poliquimioterapia (PQT). Se evaluó a 1621 pacientes (PB = 8,9% y MB = 91,1%) de 2008 a 2016, notificados en el Sistema de Estados Reaccionarios en Lepra (SisReação/RO). Prevaleció la ocurrencia durante la PQT = 997 (61,5%), y 624 (38,5%) solamente tras la PQT. La precocidad de la reacción a partir del diagnóstico se analizó mediante curvas de supervivencia de Kaplan-Meier y se compararon entre los grupos PB y MB, usando el test de log-rank de Mantel-Cox; asimismo, se construyeron modelos de regresión univariada y multivariada de Cox para identificar los factores asociados con la ocurrencia de la reacción (cociente de riesgos) y los correspondientes IC95%. En el modelo multivariado se incluyeron las variables con valores de p < 0,2 en el análisis univariado. Los PB desarrollaron una reacción de forma más precoz que los MB. Otras características se asociaron a la reacción en menor tiempo: sexo femenino y baciloscopia negativa. En el período agregado (durante y tras PQT), los PB presentaron un riesgo un 24% mayor de reacción que los multibacilares y la baciloscopia negativa aumentó este riesgo en un 40%, comparado con la baciloscopia positiva. Durante y tras el tratamiento PQT, los PB presentaron 1,3 y 1,6 veces el riesgo de ocurrencia de la reacción de los pacientes MB. De esa forma, recomendamos priorizar acciones de vigilancia para reacciones hansénicas durante y tras PQT, como medidas de prevención de discapacidades físicas, así como de mejoría en la calidad de vida de personas afectadas por la hanseniasis.

Prognostic and clinicopathological value of zwint expression levels in patients with lung adenocarcinoma: a systematic review and meta-analysis

The current study found that high Zeste White 10 interactor (ZWINT) expression is related to the poor prognosis of patients with a variety of cancers. This study mainly explored the relationship between the expression level of ZWINT and the prognosis of patients with lung adenocarcinoma (LUAD). Briefly, four English databases and two high-throughput sequencing databases were searched and relevant data for meta-analysis were extracted. Pooled mean difference and 95% confidence interval (CI) were used to assess the relationships between clinical features and the expression of ZWINT. Pooled hazard ratio and 95% CI were also used to assess the relationships between clinical features and the expression level of ZWINT. This meta-analysis was registered in PROSPERO (CRD42021249475). A total of 16 high-quality datasets comprising 2,847 LUAD patients were included in this study. Higher ZWINT expression levels were found in patients younger than 65 years, males, and smokers, and were correlated with advanced TNM stages and poor prognosis. Notably, there was no publication bias in this meta-analysis. Overall, our findings indicate that ZWINT is a potential biomarker for poor prognosis and clinicopathological outcomes of patients with LUAD.

Prevención de desnutrición aguda moderada con un suplemento alimenticio listo para consumir en niños preescolares de comunidades rurales / Moderate acute malnutrition prevention with a ready-to-use therapeutic food in pre-school children from rural communities

Resumen Introducción: La desnutrición infantil en México alcanza prevalencias de 27.5 % en zonas rurales. Objetivo: Evaluar la efectividad de un suplemento alimenticio listo para consumir (SALC) para corregir desnutrición aguda leve y prevenir desnutrición aguda moderada en preescolares de comunidades rurales. Método: Ensayo clínico aleatorizado por grupos: con y sin SALC (g-SALC y g-S/SALC); se incluyeron niños de dos a cinco años, con puntuaciones-Z de peso para la talla (pZ-P/T) mayor de −2 y menor de −1 y nivel socioeconómico bajo. Todos recibieron educación sobre nutrición, salud e higiene dos veces al mes; los niños del g-SALC debieron consumir diariamente una porción del suplemento. Se evaluó pZ-P/T al inicio y a los cuatro, seis y 12 meses. La comparación entre grupos se realizó con el modelo de riesgos proporcionales de Cox. Resultados: Respecto a la recuperación de desnutrición aguda leve, en g-SALC se observó 68.7 versus 52.1% en el grupo control en el análisis de intención para tratar, con una razón de riesgo (HR) = 1.25; en el análisis por protocolo del primer semestre se observó una HR = 1.48 y en el segundo semestre, HR = 1.56. Un paciente progresó a desnutrición aguda moderada. Conclusiones: El g-SALC mostró resolución significativamente mayor de desnutrición aguda leve.

Abstract Introduction: Child malnutrition in Mexico reaches a prevalence as high as 27.5 % in rural areas. Objective: To assess the effectiveness of a ready-to-use supplementary food (RUSF) to correct mild acute malnutrition and prevent moderate acute malnutrition in preschool children from rural communities. Method: Randomized clinical trial, with assignment to two groups: group with RUSF (RUSF-g) or group without it (non-RUSF-g); children aged from two to five years, with weight-for-height Z-scores (WHZ) between -2 and -1 and low socioeconomic status were included. All received education on nutrition, health and hygiene twice monthly; the RUSF-g children had to consume four biscuits of the supplement every day. WHZ was assessed at baseline and at four, six, and 12 months. The comparison between groups was carried out with Cox proportional hazards model. Results: With regard to mild acute malnutrition correction in the RUSF-g, 68.7 versus 52.1 % in the control group was observed in the intent-to-treat analysis, with a hazard ratio (HR) = 1.25; in the per-protocol analysis of first semester, a HR = 1.48 was observed, and in the second semester, HR = 1.56. One patient progressed to moderate acute malnutrition. Conclusions: The RUSF-g showed a significantly higher resolution of mild acute malnutrition.

Impact of comorbidities in mexican SARS-COV-2-positive patients: a retrospective analysis in a national cohort

ABSTRACT Background: The coronavirus disease 2019 outbreak is a significant challenge for health-care systems around the world. Objective: The objective of the study was to assess the impact of comorbidities on the case fatality rate (CFR) and the development of adverse events in patients positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the Mexican population. Materials and methods: We analyzed the data from 13,842 laboratory-confirmed SARS-CoV-2 patients in Mexico between January 1, 2020, and April 25, 2020. We investigated the risk of death and the development of adverse events (hospitalization, pneumonia, orotracheal intubation, and intensive care unit [ICU] admission), comparing the number of comorbidities of each patient. Results: The patient mean age was 46.6 ± 15.6 years, 42.3% (n = 5853) of the cases were women, 38.8% of patients were hospitalized, 4.4% were intubated, 29.6% developed pneumonia, and 4.4% had critical illness. The CFR was 9.4%. The risk of hospitalization (odds ratio [OR] = 3.1, 95% confidence interval [CI]: 2.7-3.7), pneumonia (OR = 3.02, 95% CI: 2.6-3.5), ICU admission (OR = 2, 95% CI: 1.5-2.7), and CFR (hazard ratio = 3.5, 95% CI: 2.9-4.2) was higher in patients with three or more comorbidities than in patients with 1, 2, or with no comorbidities. Conclusions: The number of comorbidities may be a determining factor in the clinical course and its outcomes in SARS-CoV-2-positive patients.

Worse survival of invasive melanoma patients in men and de novo lesions

Abstract Background: The incidence and mortality of melanoma is increasing in many countries, including Brazil. Survival studies are still scarce in our country, but much needed to know and address this problem better. Objective: To analyze the disease-specific survival of patients with invasive melanoma and to correlate it with clinical and histopathological variables. Methods: Retrospective cohort analysis of 565 cases of invasive melanoma in a tertiary hospital with the objective of testing variables that could be associated with a worse prognosis, such as gender, phototype, thickness, histological type and presence of pre-existing clinical lesion at the site of the tumor. Results: The worst survival rates were significantly associated with thicker tumors (p < 0.001), male sex (p = 0.014), high phototype (p = 0.047), nodular melanoma (p = 0.024) and "de novo" lesions (p = 0.005). When all variables were adjusted for melanoma thickness, male patients (p = 0.011) and "de novo" melanomas (p = 0.025) remained associated with worse survival. Study limitations: Retrospective study of a single tertiary hospital. Conclusions: Although the causes are still unknown, melanoma-specific survival was statistically worse for males and for "de novo" melanomas even after adjustment of tumor thickness.

Recurrence of Cholesteatoma: A Retrospective Study Including 1006 Patients for More than 33 Years

Abstract Introduction Cholesteatomas are benign tumors consisting of skin, and growing inside a retraction pocket in the tympanic membrane. Cholesteatomas can occupy the entirety of the middle ear, and are known for their osteolytic capabilities. Surgery is the only curative treatment for cholesteatomas. Objective To describe the risk of recurrence after first-time surgically-treated middle- ear cholesteatoma (STMEC1) on the island of Funen from 1983 to 2015. Methods Cases of STMEC1 were identified in the Danish National Hospital Register. The medical records were reviewed. Time-to-event analyses were applied. The ears were followed from STMEC1 to a secondary cholesteatoma, emigration, death, or end of follow-up. Results Records from 1,006 patients with STMEC1 were reviewed. A total of 54 patients were submitted to surgery on both ears. The total sample consisted of 1,060 ears with STMEC1; 300 were children's (< 16 years) ears, and 760 were adult's ears. The total observation time was of 12,049 years. The overall estimated proportion with recurrence 5 years after surgery was of 37% in children and of 15% in adults. The older the child was at the first surgery, the risk decreased by 7% per year. In children, canal wall up (CWU) mastoidectomy without obliteration was associated with a hazard ratio for recurrence of 1.9 (95% confidence interval [95%CI]: 1.2-3.0) compared with CWU with obliteration. Conclusion Compared with adults, children were had 2.6 times more risk of recurrence. Procedures performed without mastoidectomy had the lowest risk of recurrence. In children, obliteration was associated with a significantly lower risk of recurrence. However, patients were not randomized regarding the surgical approach; thus, the association between approach and risk of recurrence was likely influenced by confounding factors.

Long-Term Mortality in Cardioinhibitory Carotid Sinus Hypersensitivity Patient Cohort / Mortalidade de uma Coorte de Portadores da Resposta Cardioinibitória à Massagem do Seio Carotídeo - Estudo Longitudinal com 11 Anos de Seguimento

Abstract Background: Cardioinhibitory carotid sinus hypersensitivity (CICSH) is defined as ventricular asystole ≥ 3 seconds in response to 5-10 seconds of carotid sinus massage (CSM). There is a common concern that a prolonged asystole episode could lead to death directly from bradycardia or as a consequence of serious trauma, brain injury or pause-dependent ventricular arrhythmias. Objective: To describe total mortality, cardiovascular mortality and trauma-related mortality of a cohort of CICSH patients, and to compare those mortalities with those found in a non-CICSH patient cohort. Methods: In 2006, 502 patients ≥ 50 years of age were submitted to CSM. Fifty-two patients (10,4%) were identified with CICSH. Survival of this cohort was compared with that of another cohort of 408 non-CICSH patients using Kaplan-Meier curves. Cox regression was used to examine the relation between CICSH and mortality. The level of statistical significance was set at 0.05. Results: After a maximum follow-up of 11.6 years, 29 of the 52 CICSH patients (55.8%) were dead. Cardiovascular mortality, trauma-related mortality and the total mortality rate of this population were not statistically different from that found in 408 patients without CICSH. (Total mortality of CICSH patients 55.8% vs. 49,3% of non-CICSH patients; p: 0.38). Conclusion: At the end of follow-up, the 52 CICSH patient cohort had total mortality, cardiovascular mortality and trauma-related mortality similar to that found in 408 patients without CICSH.

Resumo Fundamento: A resposta cardioinibitória (RCI) à massagem do seio carotídeo (MSC) caracteriza-se por assistolia ≥ 3 segundos provocada por 5 a 10 segundos de MSC. Existe uma preocupação de que pacientes com RCI e episódios prolongados de assistolia possam falecer em consequência direta de bradiarritmia, ou em decorrência de lesão cerebral, trauma grave ou arritmia ventricular pausa dependente. Objetivos: Determinar a mortalidade total, a mortalidade cardiovascular e a mortalidade relacionada ao trauma de uma coorte de pacientes com RCI à MSC e comparar essas mortalidades com as de uma coorte de pacientes sem RCI à MSC. Métodos: Em 2006, 502 pacientes com idade igual ou superior a 50 anos foram submetidos à MSC. Destes, 52 pacientes (10,4%) foram identificados com RCI. A sobrevida desta coorte foi comparada àquela observada em uma coorte de 408 pacientes sem RCI por meio de curvas de Kaplan-Meier. A regressão de Cox foi utilizada para avaliação da relação entre a RCI à MSC e a mortalidade. Variáveis com p < 0,05 foram consideradas estatisticamente significativas. Resultados: Após seguimento máximo de 11,6 anos, 29 dos 52 portadores de RCI (55,8%) faleceram. A mortalidade total, a mortalidade cardiovascular e a mortalidade relacionada ao trauma desta coorte de pacientes não foram significativamente diferentes daquelas encontradas nos 408 pacientes sem RCI (mortalidade total com RCI: 55,8% versus 49,3% sem RCI; p: 0,38). Conclusões: No fim do seguimento, a mortalidade dos 52 portadores de RCI foi semelhante à observada em uma coorte de pacientes sem RCI. A mortalidade cardiovascular e a relacionada ao trauma também foi semelhante nas duas coortes.

Prognostic Prediction of Cardiopulmonary Exercise Test Parameters in Heart Failure Patients with Atrial Fibrillation / Previsão Prognóstica dos Parâmetros do Teste de Esforço Cardiopulmonar em Pacientes com Insuficiência Cardíaca e Fibrilação Atrial

Abstract Background: Atrial fibrillation (AF) is associated with increased mortality in heart failure (HF) patients. Objective: To evaluate whether the risk of AF patients can be precisely stratified by relation with cardiopulmonary exercise test (CPET) cut-offs for heart transplantation (HT) selection. Methods: Prospective evaluation of 274 consecutive HF patients with left ventricular ejection fraction ≤ 40%. The primary endpoint was a composite of cardiac death or urgent HT in 1-year follow-up. The primary endpoint was analysed by several CPET parameters for the highest area under the curve and for positive (PPV) and negative predictive value (NPV) in AF and sinus rhythm (SR) patients to detect if the current cut-offs for HT selection can precisely stratify the AF group. Statistical differences with a p-value <0.05 were considered significant. Results: There were 51 patients in the AF group and 223 in the SR group. The primary outcome was higher in the AF group (17.6% vs 8.1%, p = 0.038). The cut-off value of pVO2 for HT selection showed a PPV of 100% and an NPV of 95.5% for the primary outcome in the AF group, with a PPV of 38.5% and an NPV of 94.3% in the SR group. The cut-off value of VE/VCO2 slope showed lower values of PPV (33.3%) and similar NPV (92.3%) to pVO2 results in the AF group. Conclusion: Despite the fact that AF carries a worse prognosis for HF patients, the current cut-off of pVO2 for HT selection can precisely stratify this high-risk group.

Resumo Fundamento: A fibrilação atrial (FA) está associada ao aumento da mortalidade em pacientes com insuficiência cardíaca (IC). Objetivo: Avaliar se o risco de pacientes com FA pode ser estratificado com precisão em relação aos pontos de corte do teste de esforço cardiopulmonar (TECP) para seleção do transplante cardíaco (TC). Métodos: Avaliação prospectiva de 274 pacientes consecutivos com IC com fração de ejeção do ventrículo esquerdo ≤ 40%. O endpoint primário foi um composto de morte cardíaca ou TC urgente no seguimento de 1 ano. O endpoint primário foi analisado através de vários parâmetros do TECP para a maior área sob a curva e para o valor preditivo positivo (VPP) e negativo (VPN) em pacientes com FA e ritmo sinusal (RS) para detectar se os atuais pontos de corte para a seleção de TC podem estratificar com precisão o grupo com FA. Diferenças estatísticas com valor de p < 0,05 foram consideradas significativas. Resultados: Havia 51 pacientes no grupo de FA e 223 no grupo RS. O endpoint primário foi maior no grupo FA (17,6% vs. 8,1%, p = 0,038). O valor de corte de pVO2 para a seleção do TC mostrou um VPP de 100% e um VPN de 95,5% para o endpoint primário no grupo FA, com um VPP de 38,5% e um VPN de 94,3% no grupo RS. O valor de corte da inclinação VE/VCO2 apresentou valores mais baixos de VPP (33,3%) e valor semelhante de VPN (92,3%) aos resultados de pVO2 no grupo FA. Conclusões: Apesar do fato de a FA apresentar um pior prognóstico para os pacientes com IC, o atual ponto de corte de pVO2 para a seleção de TC pode estratificar com precisão esse grupo de alto risco.

Análisis de riesgo en la Medicina Nuclear Terapéutica en Cuba con enfoque integrador / Risk assessment in Therapeutic Nuclear Medicine in Cuba with an integrated approach

Introducción: El análisis de riesgo en la gestión de la calidad y seguridad permite la mejora continua de los servicios médicos en Cuba. En Medicina Nuclear Terapéutica es requisito regulador que permite la continuidad de estos servicios a la población. Objetivo: Analizar los riesgos radiológicos con enfoque integrador dirigido a causas básicas de fallo en la práctica citada. Material y métodos: Se revisó y adaptó el modelo genérico de riesgo para cada caso de estudio. Los métodos prospectivos de matriz de riesgo y análisis de modos y efectos de fallo y reactivo de aprendizaje de las lecciones de sucesos registrados fueron utilizados con el código cubano SECURE MR-FMEA versión 3.0. Se determinó el riesgo inherente, su tratamiento y el riesgo residual por práctica. Se identificaron las etapas del proceso, las medidas y las causas básicas más contribuyentes. Resultados: No se obtuvo riesgo superior al del nivel alto. La radiosinoviortesis y el tratamiento radiactivo de la policitemia vera tuvieron la mayor cantidad de modificaciones al modelo genérico. Las etapas más significativas son prescripción clínica, preparación del radiofármaco y administración. Las medidas preventivas de mayor importancia son mantener una carga de trabajo moderada para el personal, las capacitaciones de los médicos nucleares y del técnico que realiza la administración. Conclusiones: Existe una no uniformidad en el nivel de calidad y seguridad entre los servicios analizados. Para el cambio, la adopción de decisiones se ve beneficiada en su eficacia y eficiencia, al integrarse los métodos prospectivos y reactivos de análisis de riesgo(AU)

Introduction: Risk assessment in quality and safety management allows the continuous improvement of the medical services in Cuba. In Therapeutic Nuclear Medicine, it is a regulatory requirement which allows the continuity of these services to the population. Objective: To assess radiological risks with an integrated approach focused on underlying causes of failure in the mentioned practice. Material and Methods: The generic risk model was reviewed and adapted for each case study. The prospective methods of risk assessment matrix of failure modes and effects and incident learning lessons from the events registered were used applying the Cuban code SECURE MR-FMEA version 3.0. The inherent risk, treatment, and residual risk in the practice were determined. The stages of the process, measurements, and the main contributing causes were identified. Results: There was no risk higher than the high level. Radiosynoviorthesis and the radioactive treatment of the Polycythemia Vera had the greatest amount of modifications to the generic model. The most significant stages are clinical prescription, preparation of the radiopharmaceutical formulation and administration. The most important preventive measures are to maintain a moderate workload for the personnel, and the training of the nuclear physicians and the technician who performs the administration. Conclusions: There is a non-uniformity in the level of quality and safety among the NTM services in Cuba. For change, decision-making is benefited in terms of effectiveness and efficiency by integrating prospective and reactive risk assessment methods(AU)