Applicability of Deep Learning to Dynamically Identify the Different Organs of the Pelvic Floor in the Midsagittal Plane.

INTRODUCTION AND HYPOTHESIS: The objective was to create and validate the usefulness of a convolutional neural network (CNN) for identifying different organs of the pelvic floor in the midsagittal plane via dynamic ultrasound. METHODS: This observational and prospective study included 110 patients. Transperineal ultrasound scans were performed by an expert sonographer of the pelvic floor. A video of each patient was made that captured the midsagittal plane of the pelvic floor at rest and the change in the pelvic structures during the Valsalva maneuver. After saving the captured videos, we manually labeled the different organs in each video. Three different architectures were tested-UNet, FPN, and LinkNet-to determine which CNN model best recognized anatomical structures. The best model was trained with the 86 cases for the number of epochs determined by the stop criterion via cross-validation. The Dice Similarity Index (DSI) was used for CNN validation. RESULTS: Eighty-six patients were included to train the CNN and 24 to test the CNN. After applying the trained CNN to the 24 test videos, we did not observe any failed segmentation. In fact, we obtained a DSI of 0.79 (95% CI: 0.73 - 0.82) as the median of the 24 test videos. When we studied the organs independently, we observed differences in the DSI of each organ. The poorest DSIs were obtained in the bladder (0.71 [95% CI: 0.70 - 0.73]) and uterus (0.70 [95% CI: 0.68 - 0.74]), whereas the highest DSIs were obtained in the anus (0.81 [95% CI: 0.80 - 0.86]) and levator ani muscle (0.83 [95% CI: 0.82 - 0.83]). CONCLUSIONS: Our results show that it is possible to apply deep learning using a trained CNN to identify different pelvic floor organs in the midsagittal plane via dynamic ultrasound.

The Application of Shear Wave Elastography to Determine the Elasticity of the Levator Ani Muscle and Vaginal Tissue in Patients With Pelvic Organ Prolapse.

OBJECTIVES: The changes of the extracellular matrix of the connective tissue have significantly contributed to the incidence of pelvic organ prolapse (POP). It seems reasonable that sonoelastography could be a useful tool to evaluate the elasticity of pelvic floor tissue in patients with POP and compare it to those without POP. The main aim of this pilot study was to determine if there are differences in the elasticity of the levator ani muscle (LAM) and vaginal tissue between patients with and without POP. METHODS: Prospective observation study, including 60 patients (30 with POP and 30 without POP). Sonoelastography was performed to evaluate the elasticity (in kilopascals, kPa) of the following regions of interest: vagina at the level of middle third of the urethra; vagina at the level of the bladder trigone; vagina in the anterior and posterior fornix; vagina at the level of middle third of the anorectal canal; posterior third of the LAM. RESULTS: A total of 60 patients completed the study (30 with POP, 30 without POP). In the POP group, 18/30 (60%) had an anterior vaginal wall prolapse, 3/30 (10%) a uterine prolapse, 15/30 (50%) a rectocele, and 6/30 (20%) a enterocele. Patients with POP had higher elasticity in all anatomical study areas, with statistically significant differences in the anterior fornix (13.6 vs 11.2 kPa; P: .012). A multiple regression (controlling age, menopausal stage, and parity) allowed to detect statistically significant differences in the elasticity of the middle third of the urethra (P: .03) and the middle third of the anorectal canal (P: .019). CONCLUSION: It is possible to evaluate the elasticity of the LAM and vaginal tissue using sonoelastography, detecting a higher elasticity in patients with POP than in those without POP.

Is the Presence of Levator Ani Muscle Avulsion Relevant for the Diagnosis of Uterine Prolapse?

OBJECTIVE: To determine if the addition of the assessment of levator ani muscle (LAM) avulsion to the measurement of the difference in the pubis-uterine fundus distance between rest and with the Valsalva maneuver could increase the diagnostic capacity of ultrasound for uterine prolapse (UP). METHODS: This multicenter, observational and prospective study included 145 patients. Ultrasound assessment was performed, establishing the diagnosis of UP as a difference between the pubic-uterine fundus distance at rest and during the Valsalva maneuver ≥15 mm (standard technique), while LAM avulsion was defined as an abnormal LAM insertion in three central slices using multislice ultrasound. A binary multivariate logistic regression model was made using nonautomated methods to predict surgical UP (general population, premenopausal, and postmenopausal patients), including the difference between the pubis-uterine fundus distance at rest and with the Valsalva maneuver as well as LAM avulsion. RESULTS: A total of 143 patients completed the study. The addition of LAM avulsion criteria to the standard dynamic distance-based protocol for the diagnosis of UP resulted in a higher sensitivity for the general population (79.7 vs 68.1%) as well as for premenopausal (89.3 vs 79.9%) and postmenopausal patients (76 vs 66.1%). In contrast, the standard technique showed a higher specificity than the model based on the standard technique associated with LAM avulsion for the general population (89.2 vs 74.3%) and premenopausal women (91.7 vs 63.2%). For postmenopausal patients, the model based on the standard technique associated with LAM avulsion had a higher sensitivity (76 vs 66.1%) and specificity (91.7 vs 86.8%) than the ultrasound diagnosis of UP. CONCLUSION: The implementation of the assessment of LAM avulsion in the ultrasound diagnosis of UP is useful in postmenopausal patients, increasing sensitivity and specificity relative to the ultrasound assessment based only on the difference between the pubis-uterine fundus distance at rest and with the Valsalva maneuver.

A nationwide study of chronic pain prevalence in the general spanish population: identifying clinical subgroups through cluster analysis.

OBJECTIVE: This study aims to assess the prevalence of chronic pain, its characteristics, and its impact on the general Spanish population. Also, to establish chronic pain patient subgroups according to the characteristics of pain and to identify variables specifically associated with each subgroup. DESIGN: Telephone-based, cross-sectional nationwide study. SUBJECTS: A sample of 1,957 individuals representative of the Spanish population. METHODS: Data were collected through telephone interviews. A subject was considered to have chronic pain if they had suffered pain (at least 4 days a week) during the last 3 months. The subjects were divided into two subgroups through a cluster analysis, and a regression model was established to determine the variables most specifically associated with these subgroups. RESULTS: The prevalence of chronic pain was 16.6% (95% confidence interval: 14.9-18.3) and among these subjects, more than 50% referred to limitations in their daily activities, 30% felt sad and/or anxious, and 47.2% indicated that their pain was affecting their family life. Two subgroups of subjects with pain were identified: 1) characterized by generalized pain in more than one location and of a long evolution (150 months); and 2) characterized by pain localized to only one site with a shorter duration (100 months). Individuals who felt anxious because of their pain and those who considered that their pain was affecting their family were more likely to belong to group 1. CONCLUSIONS: Pain affects an important proportion of the Spanish adult population and that it has a strong personal impact. Two pain groups were clearly distinguished by their clinical characteristics.

Comparison of the MDRD and the CKD-EPI equations to estimate the glomerular filtration rate in the general population.

BACKGROUND AND OBJECTIVE: The Chronic Kidney Disease Epidemiology Collaboration (CDK-EPI) equation has been proposed as a replacement for the Modification of Diet in Renal Disease (MDRD) equation to estimate the glomerular filtration rate, but this equation has not yet been evaluated in the general population. PATIENTS AND METHODS: Cross-sectional analysis of a random sample of 858 participants from the general population aged 50-75 years without known kidney disease. The prevalence of low eGFR (< 60 mL/min/1.73 m(2)) was assessed with the MDRD and the CKD-EPI equations in the overall sample and in normoalbuminuric individuals. RESULTS: With the MDRD equation the median eGFRs (interquartile range) in men/women were 63.3(12.2)/56.7(9.4)mL/min/1.73 m(2), and with the CKD-EPI equation 66.6(14.2)/61.3(11.6) mL/min/1.73 m(2). The prevalence of low eGFR in men/women was 35.2%/68.5% and 25.1%/45.7% with the MDRD and the CKD-EPI equations, respectively. Normoalbuminuric women without risk factors for CKD experienced the most pronounced reduction in the number of cases with low eGFR with the CKD-EPI equation. The prevalence of renal impairment in this subgroup still remained even greater than that in men with diabetes, hypertension, or cardiovascular disease. CONCLUSIONS: Compared with the MDRD, the CKD-EPI equation generates a substantial reduction in the prevalence of renal impairment in subjects with diabetes, hypertension, cardiovascular disease, and in subjects without risk factors. The prevalence of renal impairment in normoalbuminuric females may be still overestimated with the CKD-EPI equation.

Use and satisfaction with the Healthcare System of the chronic pain patients in Spain: results from a nationwide study.

OBJECTIVE: To analyze the use of healthcare resources by chronic pain (CP) patients in Spain and their satisfaction with them. RESEARCH DESIGN AND METHODS: A nationwide, cross-sectional study was carried out on a representative sample of 1957 Spanish adults. A telephone survey was conducted with the aim of analyzing the prevalence of CP, the characteristics and consequences of pain, the use of healthcare resources and patients' satisfaction with them. Descriptive, bivariate and multivariate analyses were performed. RESULTS: Of the 1957 subjects interviewed, 325 suffered CP. The mean duration of CP was 10 years (SD: 11.3) and 48.9% of the CP sufferers reported severe/unbearable pain. Moreover, about 30% felt sad/very sad or anxious/very anxious, 24.4% had been on sick leave, 12% had left/lost their jobs and 47.2% considered their pain affected their families. Likewise, 92.9% had consulted a healthcare professional due to their CP, on average 3.49 times (SD: 3.9), and 69.2% took medication. In addition, 67.3% and 63.8% were satisfied/very satisfied with the care and the healthcare information they received, respectively. Individuals who reported headache (OR = 0.34) and feeling sad (OR =0.38) were least satisfied with the care they received. In addition, CP sufferers who made greater use of consultations were those who had left/lost their jobs (ß = 1.44), those who took medication (ß = 1.67), those who considered their pain affected their families (ß = 0.97) and those with a shorter duration of pain (ß = -0.003). CONCLUSIONS: CP produces relevant demands on healthcare resources, conditioned by the consequences within the family and the effects on their employment. To achieve greater patient satisfaction, professionals need to pay particular attention to certain sites of pain and to patients' mental health.

Metabolic syndrome does not improve the prediction of 5-year cardiovascular disease and total mortality over standard risk markers. Prospective population based study.

Metabolic syndrome (MS) is widely believed to be an important risk factor for cardiovascular disease (CVD). We assessed whether a model based on MS improved prediction of CVD and total mortality over the Framingham's general CVD system (FRS) and whether MS was better than its individual components. Prospective cohort study of 855 participants randomly selected from the general population. Cox proportional hazards models were used to estimate the hazard ratios selecting a composite endpoint of CVD and total mortality. The performance of the FRS was compared with that of 4 MS-based models that differed in their use of individual components of MS as well as in the use of optimized cut-points of MS. The assessment included metrics of discrimination, calibration, and risk reclassification. Of all the models, only the model containing the 5 optimized components of MS improved model fit (deviance 10.7, P = 0.005), discrimination (difference of areas under the receiving operating curves 0.018), and risk reclassification in participants without events (net reclassification index 5.97, P = 0.01). The addition of optimized waist circumference to the FRS model improved the performance more than any other MS-based model. Every model containing the dichotomous definition of MS failed to improve model fit, discrimination, and risk reclassification. MS did not contribute predictive information over the FRS for the 5-year risk of CVD and total mortality. Some individual components of MS, in particular waist circumference, might play a role as part of the FRS provided their cut-off points are optimized.

[Prevalence of obesity, diabetes, hypertension, hypercholesterolemia and metabolic syndrome in over 50-year-olds in Sanlúcar de Barrameda, Spain]. / Prevalencia de obesidad, diabetes, hipertensión, hipercolesterolemia y síndrome metabólico en adultos mayores de 50 años de Sanlúcar de Barrameda.

INTRODUCTION AND OBJECTIVES: The Spanish province of Cádiz has some of the poorest socioeconomic conditions and the highest cardiovascular morbidity and mortality rates in the country. The aim of this study was to investigate the prevalence of cardiovascular risk factors in the adult population of the city of Sanlúcar de Barrameda in Cádiz. METHODS: This cross-sectional population-based study involved 858 randomly selected individuals aged 50-75 years. Age- and sex-adjusted prevalences of the main cardiovascular risk factors were obtained. RESULTS: The mean age of the study population was 61.5 years and 53.6% were women. Overall, 46% of men and 61.7% of women were illiterate; 23.7% and 7.9%, respectively, were current smokers; 30.9% and 44.8% had a sedentary lifestyle; 54% and 55.9% were obese; 29.4% and 26.1% had diabetes; 45% and 52.4% had hypertension; 40.9% and 45.1% had hypercholesterolemia; and 58.8% and 57% had metabolic syndrome as defined by NCEP/ATP-III criteria. The prevalence of all cardiovascular risk factors, except smoking, increased with age. Significant inverse associations were observed between educational level and obesity in men and between educational level and diabetes and metabolic syndrome in women. CONCLUSIONS: The prevalence of cardiovascular risk factors in individuals aged 50-75 years in Sanlúcar de Barrameda was extremely high. The prevalences of obesity, diabetes and metabolic syndrome were among the highest ever reported in Spain. A very low educational level may underlie these adverse findings.

Comparison of the MDRD and the CKD-EPI equations to estimate the glomerular filtration rate in the general population

Background and objective: The Chronic Kidney Disease Epidemiology Collaboration (CDK-EPI) equation has been proposed as a replacement for the Modification of Diet in Renal Disease (MDRD) equation to estimate the glomerular filtration rate, but this equation has not yet been evaluated in the general population. Patients and methods: Cross-sectional analysis of a random sample of 858 participants from the general population aged 50–75 years without known kidney disease. The prevalence of low eGFR (<60mL/min/1.73m2) was assessed with the MDRD and the CKD-EPI equations in the overall sample and in normoalbuminuric individuals. Results: With the MDRD equation the median eGFRs (interquartile range) in men/women were 63.3(12.2)/56.7(9.4) mL/min/1.73m2, and with the CKD-EPI equation 66.6(14.2)/61.3(11.6) mL/min/1.73m2. The prevalence of low eGFR in men/women was 35.2%/68.5% and 25.1%/45.7% with the MDRD and the CKD-EPI equations, respectively. Normoalbuminuric women without risk factors for CKD experience the most pronounced reduction in the number of cases with low eGFR with the CKD-EPI equation. The prevalence of renal impairment in this subgroup still remained even greater than that in men with diabetes, hypertension, or cardiovascular disease. Conclusions: Compared with the MDRD, the CKD-EPI equation generates a substantial reduction in the prevalence of renal impairment in subjects with diabetes, hypertension, cardiovascular disease, and in subjects without risk factors. The prevalence of renal impairment in normoalbuminuric females may be still overestimated with the CKD-EPI equation (AU)

Fundamento y objetivo: La ecuación Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) ha sido propuesta para sustituir a la actualmente recomendada Modification of Diet in Renal Disease (MDRD) para el cálculo de la tasa de filtrado glomerular (TFG), si bien no ha sido aún evaluada en la población general. Pacientes y Método: Estudio transversal de una muestra aleatoria de 858 individuos de la población general con edades entre 50–75 años sin enfermedad renal conocida. Comparación de la prevalencia de una TFG<60ml/min/1,73m2 calculada con las ecuaciones MDRD y CKD-EPI en toda la muestra y en el subgrupo de individuos normoalbuminúricos (cociente albúmina/creatinina<30mg/g). Resultados: Con la ecuación MDRD la mediana de la TFG (rango intercuartílico) en varones/mujeres fue de 63,3 (12,2)/56,7 (9,4) ml/min/1,73m2, y con la ecuación CKD-EPI 66,6 (14,2)/61,3 (11,6)ml/min/1,73m2, respectivamente. La prevalencia de una TFG baja en varones/mujeres fue del 35,2–68,5%, y del 25,1–45,7% con las ecuaciones MDRD y CKD-EPI, respectivamente. El grupo de mujeres normoalbuminúricas sin factores de riesgo para enfermedad renal crónica presentó la mayor reducción en la prevalencia de una TFG baja con la ecuación CKD-EPI. Sin embargo, la prevalencia en este grupo se mantuvo incluso más elevada que en el de los varones con diabetes, hipertensión o enfermedad cardiovascular. Conclusiones: Comparada con la ecuación MDRD, la ecuación CKD-EPI produce una importante reducción en la prevalencia de insuficiencia renal en individuos con diabetes, hipertensión, enfermedad cardiovascular, y en individuos sin factores de riesgo. La prevalencia de insuficiencia renal en mujeres normoalbuminúricas calculada con la ecuación CKD-EPI puede estar aún sobreestimada (AU)

Prevalencia de obesidad, diabetes, hipertensión, hipercolesterolemia y síndrome metabólico en adultos mayores de 50 años de Sanlúcar de Barrameda / Prevalence of obesity, diabetes, hypertension, hypercholesterolemia and metabolic syndrome in over 50-year-olds in Sanlúcar de Barrameda, Spain

Introducción y objetivos. Cádiz es una de las provincias con los marcadores socioeconómicos más desfavorables y la mayor morbimortalidad cardiovascular de España. Se estudia la prevalencia de los factores de riesgo cardiovascular en la población adulta de Sanlúcar de Barrameda. Métodos. Estudio poblacional con selección aleatoria de una muestra representativa constituida por 858 individuos con edades entre 50 y 75 años. Descripción de la prevalencia de los factores de riesgo cardiovascular principales ajustada por edad y sexo. Resultados. La media de edad de los pacientes era 61,5 años, con un 53,6% de mujeres. La prevalencia de sujetos sin estudios en varones y mujeres fue del 46 y el 61,7%; de tabaquismo activo, el 23,7 y el 7,9%; de sedentarismo, el 30,9 y el 44,8%; de obesidad, el 54 y el 55,9%; de diabetes, el 29,4 y el 26,1%; de hipertensión, el 45 y el 52,4%; de hipercolesterolemia, el 40,9 y el 45,1%, y de síndrome metabólico (NCEP/ATP-III), el 58,8 y el 57%. Con excepción del tabaquismo, la prevalencia de todos los factores de riesgo aumentó con la edad. Se aprecia una asociación significativa e inversa del nivel de estudios con la obesidad en varones, y con la diabetes y el síndrome metabólico en mujeres. Conclusiones. La prevalencia de los factores de riesgo cardiovascular en adultos de 50 a 75 años de Sanlúcar de Barrameda es extraordinariamente elevada. Las prevalencias de obesidad, diabetes y síndrome metabólico se encuentran entre las más elevadas de las que se ha comunicado hasta el momento en España. Un nivel de estudios muy bajo puede estar en relación con un perfil de riesgo tan elevado (AU)

Introduction and objectives. The Spanish province of Cadiz has some of the poorest socioeconomic conditions and the highest cardiovascular morbidity and mortality rates in the country. The aim of this study was to investigate the prevalence of cardiovascular risk factors in the adult population of the city of Sanlucar de Barrameda in Cadiz. Methods. This cross-sectional population-based study involved 858 randomly selected individuals aged 50-75 years. Age- and sex-adjusted prevalences of the main cardiovascular risk factors were obtained. Results. The mean age of the study population was 61.5 years and 53.6% were women. Overall, 46% of men and 61.7% of women were illiterate; 23.7% and 7.9%, respectively, were current smokers; 30.9% and 44.8% had a sedentary lifestyle; 54% and 55.9% were obese; 29.4% and 26.1% had diabetes; 45% and 52.4% had hypertension; 40.9% and 45.1% had hypercholesterolemia; and 58.8% and 57% had metabolic syndrome as defined by NCEP/ATP-III criteria. The prevalence of all cardiovascular risk factors, except smoking, increased with age. Significant inverse associations were observed between educational level and obesity in men and between educational level and diabetes and metabolic syndrome in women. Conclusions. The prevalence of cardiovascular risk factors in individuals aged 50-75 years in Sanlucar de Barrameda was extremely high. The prevalences of obesity, diabetes, and metabolic syndrome were among the highest ever reported in Spain. A very low educational level may underlie these adverse findings (AU)