Symptomatic gallstone disease: Recurrence patterns and risk factors for relapse after first admission, the RELAPSTONE study.

BACKGROUND: Delayed cholecystectomy in patients with symptomatic gallstone disease is associated with recurrence. Limited data on the recurrence patterns and the factors that determine them are available. OBJECTIVE: We aimed to determine the pattern of relapse in each symptomatic gallstone disease (acute pancreatitis, cholecystitis, cholangitis, symptomatic choledocholithiasis, and biliary colic) and determine the associated factors. METHODS: RELAPSTONE was an international multicenter retrospective cohort study. Patients (n = 3016) from 18 tertiary centers who suffered a first episode of symptomatic gallstone disease from 2018 to 2020 and had not undergone cholecystectomy during admission were included. The main outcome was relapse-free survival. Kaplan-Meier curves were used in the bivariate analysis. Multivariable Cox regression models were used to identify prognostic factors associated with relapses. RESULTS: Mean age was 76.6 [IQR: 59.7-84.1], and 51% were male. The median follow-up was 5.3 months [IQR 2.1-12.4]. Relapse-free survival was 0.79 (95% CI: 0.77-0.80) at 3 months, 0.71 (95% CI: 0.69-0.73) at 6 months, and 0.63 (95% CI: 0.61-0.65) at 12 months. In multivariable analysis, older age (HR = 0.57; 95% CI: 0.49-0.66), sphincterotomy (HR = 0.58, 95% CI: 0.49-0.68) and higher leukocyte count (HR = 0.79; 95% CI: 0.70-0.90) were independently associated with lower risk of relapse, whereas higher levels of alanine aminotransferase (HR = 1.22; 95% CI: 1.02-1.46) and multiple cholelithiasis (HR = 1.19, 95% CI: 1.05-1.34) were associated with higher relapse rates. CONCLUSION: The relapse rate is high and different in each symptomatic gallstone disease. Our independent predictors could be useful for prioritizing patients on the waiting list for cholecystectomies.

Prognostic Value of a New Tool (the 3D/3D+) for Predicting 30-Day Mortality in Emergency Department Patients Aged 75 Years and Older.

The 3D/3D+ multidimensional geriatric assessment tool provides an optimal model of emergency care for patients aged 75 and over who attend the Emergency Department (ED). The baseline, or static, component (3D) stratifies the degree of frailty prior to the acute illness, while the current, or dynamic, component (3D+) assesses the multidimensional impact caused by the acute illness and helps to guide the choice of care facility for patients upon their discharge from the ED. The objective of this study was to evaluate the prognostic value of the 3D/3D+ to predict short- and long-term adverse outcomes in ED patients aged 75 years and older. Multivariable logistic regression models were used to identify the predictors of mortality 30 days after 3D/3D+ assessment. Two hundred and seventy-eight patients (59.7% women) with a median age of 86 years (interquartile range: 83-90) were analyzed. According to the baseline component (3D), 83.1% (95% CI: 78.2-87.3) presented some degree of frailty. The current component (3D+) presented alterations in 60.1% (95% CI: 54.1-65.9). The choice of care facility at ED discharge indicated by the 3D/3D+ was considered appropriate in 96.4% (95% CI: 93.0-98.0). Thirty-day all-cause mortality was 19.4%. Delirium and functional decline were the dimensions on the 3D/3D+ that were independently associated with 30-day mortality. These two dimensions had an area under receiver operating characteristic of 0.80 (95% CI: 0.73-0.86) for predicting 30-day mortality. The 3D/3D+ tool enhances the provision of comprehensive care by ED professionals, guides them in the choice of patients' discharge destination, and has a prognostic validity that serves to establish future therapeutic objectives.

Low complement levels are related to poor obstetric outcomes in women with obstetric antiphospholipid syndrome. The EUROAPS Registry Study Group.

INTRODUCTION: Obstetric antiphospholipid syndrome (OAPS) is an autoimmune disease related to antiphospholipid antibodies (aPL) with primaryinflammatory injury followed by clot cascade activation and thrombus formation. Complement system activation and their participation in aPL-related thrombosis is unclosed. METHODS: We haveanalysed adverse pregnancy outcomes (APO) related to low complement (LC) levels in a cohort of 1048 women fulfilling classification criteria for OAPS. RESULTS: Overall, 223 (21.3%) women presented LC values, during pregnancy. The length of pregnancy was shorter in OAPS women with LC compared to those with normal complement (NC) (median: 33 weeks, interquartile range: [24-38] vs. 35 weeks [27-38]; p = 0.022). Life new-born incidence was higher in patients with NC levels than in those with LC levels (74.4% vs. 67.7%; p = 0.045). Foetal losses were more related to women with triple or double aPL positivity carrying LC than NC values (16.3% vs. 8.0% NC; p = 0.027). Finally, some placental vasculopathies were affected in OAPS patients with LC as late Foetal Growth Restriction (FGR >34 weeks) rise to 7.2% in women with LC vs. 3.2% with NC (p = 0.007). DISCUSSION: Data from our registry indicate that incidence of APO was higher in OAPS women with LC levels and some could be reverted by the correct treatment.

Effect of goal-directed haemodynamic therapy guided by non-invasive monitoring on perioperative complications in elderly hip fracture patients within an enhanced recovery pathway.

BACKGROUND: Goal-directed haemodynamic therapy (GDHT) has been shown to reduce morbidity and mortality in high-risk surgical patients. However, there is little evidence of its efficacy in patients undergoing hip fracture surgery. This study aims to evaluate the effect of GDHT guided by non-invasive haemodynamic monitoring on perioperative complications in patients undergoing hip fracture surgery. METHODS: Patients > 64 years undergoing hip fracture surgery within an enhanced recovery pathway (ERP) were enrolled in this single-centre, non-randomized, intervention study with a historical control group and 12-month follow-up. Exclusion criteria were patients with pathological fractures, traffic-related fractures and refractures. Control group (CG) patients received standard care treatment. Intervention group (IG) patients received a GDHT protocol based on achieving an optimal stroke volume, in addition to a systolic blood pressure > 90 mmHg and an individualized cardiac index. No changes were made between groups in the ERP during the study period. Primary outcome was percentage of patients who developed intraoperative haemodynamic instability. Secondary outcomes were intraoperative arrhythmias, postoperative complications (cardiovascular, respiratory, infectious and renal complications), administered fluids, vasopressor requirements, perioperative transfusion, length of hospital stay, readmission and 1-year survival. RESULTS: In total, 551 patients (CG=272; IG=279) were included. Intraoperative haemodynamic instability was lower in the IG (37.5% vs 28.0%; p=0.017). GDHT patients had fewer postoperative cardiovascular (18.8% vs 7.2%; p < 0.001), respiratory (15.1% vs 3.6%; p<0.001) and infectious complications (21% vs 3.9%; p<0.001) but not renal (12.1% vs 33.7%; p<0.001). IG patients had less vasopressor requirements (25.5% vs 39.7%; p<0.001) and received less fluids [2.600 ml (IQR 1700 to 2700) vs 850 ml (IQR 750 to 1050); p=0.001] than control group. Fewer patients required transfusion in GDHT group (73.5% vs 44.4%; p<0.001). For IG patients, median length of hospital stay was shorter [11 days (IQR 8 to 16) vs 8 days; (IQR 6 to 11) p < 0.001] and 1-year survival higher [73.4% (95%CI 67.7 to 78.3 vs 83.8% (95%CI 78.8 to 87.7) p<0.003]. CONCLUSIONS: The use of GDHT decreases intraoperative complications and postoperative cardiovascular, respiratory and infectious but not postoperative renal complications. This strategy was associated with a shorter hospital stay and increased 1-year survival. TRIAL REGISTRATION: ClinicalTrials.gov NCT02479321 .

[3D/3D+ as a tool for rapid geriatric assessment and adequacy of the care resource at discharge from the Emergency Department]. / Las 3D/3D+ como herramienta de valoración geriátrica rápida y de adecuación del recurso asistencial al alta de los Servicios de Urgencias.

OBJECTIVE: Assess the 3D/3D+ rapid geriatric assessment tool for the early detection of frailty, its usefulness to identify the effects of the acute process on the functional, physical, cognitive and socioenvironmental dimensions, as well as the medications that may have triggered the patient's reason for visit. Finally, assess the usefulness of 3D/3D+ together with the clinical diagnosis to adequate care resource at discharge from the emergency department (ED). METHOD: Retrospective observational cohort study. Patients ≥75 years old, with clinical complexity visited at the ED were included. Basal frailty status was assessed using 3D (basal component), and the multidimensional impact of the acute process using 3D+ (current component). The main dependent variable was adequacy of the care resource at ED discharge. RESULTS: 278 patients were included, mean age 86 years (interquartile range: 83-90), 59.7% were women. According to the basal component (3D), 83.1% (95%CI: 78.2-87.3) presented some degree of frailty. The current component (3D+) was altered in 60.1% (95%CI: 54.1-65.9). The adequacy of ED discharge was correct in 96.4% (95%CI: 93.0-98.0). One out of 4patients was admitted to a medicine ward. CONCLUSIONS: 3D/3D+ facilitates an optimal model of emergency care adapted to patients ≥ 75 years old treated in EDs. It stratifies the level of frailty (3D), detects the severity of patients' acute problems (3D+) and contributes to decision-making regarding the most appropriate care resource at ED discharge.

Model to predict risk for hospital admission and indicate the safety of reverse triage in a hospital emergency department: a prospective validation study. / Validación prospectiva de un modelo predictivo de ingreso y orientar la seguridad de la derivación inversa desde el triaje de los servicios de urgencias hospitalarios.

OBJECTIVES: To prospectively validate a model to predict hospital admission of patients given a low-priority classification on emergency department triage and to indicate the safety of reverse triage. MATERIAL AND METHODS: Single-center observational study of a prospective cohort to validate a risk model incorporating demographic and emergency care process variables as well as vital signs. The cohort included emergency visits from patients over the age of 15 years with priority level classifications of IV and V according to the Andorran-Spanish triage system (Spanish acronym, MAT-SET) between October 2018 and June 2019. The area under the receiver operating characteristic curve (AUC) of the model was calculated to evaluate discrimination. Based on the model, we identified cut-off points to distinguish patients with low, intermediate, or high risk for hospital admission. RESULTS: A total of 2110 emergencies were included in the validation cohort; 109 patients (5.2%) were hospitalized. The median age was 43.5 years (interquartile range, 31-60.3 years); 55.5% were female. The AUC was 0.71 (95% CI, 0.64-0.75). The model identified 357 patients (16.9%) at low risk of hospitalization and 240 (11.4%) at high risk. A total of 15.8% of the high-risk patients and 2.8% of the low-risk patients were hospitalized. CONCLUSION: The validated model is able to identify risk for hospitalization among patients classified as low priority on triage. Patients identified as having high risk of hospitalization could be offered preferential treatment within the same level of priority at triage, while those at low risk of admission could be referred to a more appropriate care level on reverse triage.

OBJETIVO: Validar prospectivamente un modelo predictivo de ingreso hospitalario para los pacientes atendidos en el servicio de urgencias hospitalario (SUH) con baja prioridad de visita y determinar la capacidad predictiva del modelo para realizar con seguridad la derivación inversa. METODO: Estudio observacional unicéntrico de una cohorte prospectiva de validación de un modelo predictivo basado en variables demográficas, de proceso y las constantes vitales (modelo 3). Se incluyeron los episodios de pacientes >15 años con prioridades IV y V MAT-SET atendidos entre octubre 2018 y junio 2019. Se evaluó la discriminación mediante el área bajo la curva de la característica operativa del receptor (ABC). Para determinar la capacidad de discriminación se crearon 3 categorías de riesgo: bajo, intermedio y alto. RESULTADOS: Se incluyeron 2.110 episodios, de los cuales 109 (5,2%) ingresaron. La mediana de edad fue de 43,5 años (RIC 31-60,3) con un 55,5% de mujeres. El ABC fue de 0,71 (IC 95%: 0,64-0,75). Según el modelo predictivo, 357 episodios (16,9%) puntuaron de bajo riesgo de ingreso y 240 (11,4%) de alto riesgo. El porcentaje de ingreso observado de los pacientes clasificados de alto riesgo fue de 15,8% mientras que el de los pacientes de bajo riego fue de 2,8%. CONCLUSIONES: El modelo predictivo validado permite estratificar el riesgo de ingreso de los pacientes con baja prioridad de visita. Los pacientes con alto riesgo de ingreso se les podría ofrecer una atención preferente dentro del mismo nivel de prioridad, mientras que los de bajo riesgo podrían ser redirigidos al recurso asistencial más adecuado (derivación inversa).

Compound Endoscopic Morphological Features for Identifying Non-Pedunculated Lesions ≥20 mm with Intramucosal Neoplasia.

BACKGROUND: The major limitation of piecemeal endoscopic mucosal resection (EMR) is the inaccurate histological assessment of the resected specimen, especially in cases of submucosal invasion. OBJECTIVE: To classify non-pedunculated lesions ≥20 mm based on endoscopic morphological features, in order to identify those that present intramucosal neoplasia (includes low-grade neoplasia and high-grade neoplasia) and are suitable for piecemeal EMR. DESIGN: A post-hoc analysis from an observational prospective multicentre study conducted by 58 endoscopists at 17 academic and community hospitals was performed. Unbiased conditional inference trees (CTREE) were fitted to analyse the association between intramucosal neoplasia and the lesions' endoscopic characteristics. RESULT: 542 lesions from 517 patients were included in the analysis. Intramucosal neoplasia was present in 484 of 542 (89.3%) lesions. A conditional inference tree including all lesions' characteristics assessed with white light imaging and narrow-band imaging (NBI) found that ulceration, pseudodepressed type and sessile morphology changed the accuracy for predicting intramucosal neoplasia. In ulcerated lesions, the probability of intramucosal neoplasia was 25% (95%CI: 8.3-52.6%; p < 0.001). In non-ulcerated lesions, its probability in lateral spreading lesions (LST) non-granular (NG) pseudodepressed-type lesions rose to 64.0% (95%CI: 42.6-81.3%; p < 0.001). Sessile morphology also raised the probability of intramucosal neoplasia to 86.3% (95%CI: 80.2-90.7%; p < 0.001). In the remaining 319 (58.9%) non-ulcerated lesions that were of the LST-granular (G) homogeneous type, LST-G nodular-mixed type, and LST-NG flat elevated morphology, the probability of intramucosal neoplasia was 96.2% (95%CI: 93.5-97.8%; p < 0.001). CONCLUSION: Non-ulcerated LST-G type and LST-NG flat elevated lesions are the most common non-pedunculated lesions ≥20 mm and are associated with a high probability of intramucosal neoplasia. This means that they are good candidates for piecemeal EMR. In the remaining lesions, further diagnostic techniques like magnification or diagnostic +/- therapeutic endoscopic submucosal dissection should be considered.

Tumour Markers in the Differential Diagnosis of Patients With Isolated Involuntary Weight Loss.

BACKGROUND/AIM: Paraneoplastic syndrome symptoms include isolated involuntary weight loss (IIWL). The differential diagnosis of cancer from other diseases may require a significant number of tests. Tumour markers (TMs) can be used for the diagnosis and stratification of patients according to cancer risk. PATIENTS AND METHODS: This study included 606 patients (48% females) seen at the rapid diagnostic unit for IIWL. We determined the levels of TMs carcinoembryonic antigen, carbohydrate antigen 19-9, soluble fragments of cytokeratin 19, carbohydrate antigen 15-3, carbohydrate antigen 125, neuron specific enolase, alpha-fetoprotein, prostatic specific antigen using the multiparametric analyser COBAS 601. Two cut-off points were established, the upper reference limit described by the manufacturer and a high cut-off point suggested by Molina et al., to stratify patients according to cancer risk. RESULTS: Patients were classified according to TM levels as follows: I) all TMs below the upper reference limit; II) highest number of TMs between the two cut-offs; III) at least one TM above the higher cut-off. The odds ratio for malignancy was 4.3 for group II and 248 for group III. These results indicate that when at least one TM is above the higher cut-off, neoplasia is highly probable. CONCLUSION: TM determination allowed to establish cancer risk in patients with IIWL.

Etiologies and 12-month mortality in patients with isolated involuntary weight loss at a rapid diagnostic unit.

BACKGROUND: Numerous studies on involuntary weight loss (IWL) have been published since the 1980s, although most of them have included small samples of patients with specific symptoms. The aim of the present study was to determine the causes, demographic and clinical characteristics and mortality at 12 months in patients attended at a rapid diagnostic unit (RDU) for isolated IWL. METHODS: A single-center retrospective observational study including all patients presenting to the RDU for isolated IWL between 2005 and 2013. The following data were recorded: demographic and clinical variables, results of complementary tests (blood tests, x-rays, computed tomography scan and digestive endoscopy), main diagnosis and vital status at 12 months. RESULTS: Seven hundred and ninety-one patients met the criteria for IWL. Mean age was 67.9 years (SD 4.7), 50.4% were male and mean weight loss was 8.3 kg (SD 4.7). The cause for IWL was malignant disease in 23.6% of patients, non-malignant organic disease in 44.5%, psychiatric disorder in 29.0% and unknown in 3.2%. Overall mortality at 12 months was 18.6% (95%CI: 16.1-21.6). The mortality rate was highest in the group with malignancy (61.1%; 95%CI: 54.2-68.2). CONCLUSIONS: Almost a quarter of all patients attended at the RDU for IWL were diagnosed with cancer. Mortality at 12 months was higher in this group than in the other three. Malignancy should therefore be ruled out during the first visit for patients attended for IWL.

Bleeding and antithrombotic therapy during pregnancy in women with poor aPL-related obstetric outcomes: A survey of 1075 cases from EUROAPS registry∗.

BACKGROUND: The combination of low-dose aspirin (LDA) and low-molecular-weight heparin (LMWH) until the end of gestation are the currently the accepted standard of care for the treatment of antiphospholipid-related obstetric disorders. In refractory cases, hydroxychloroquine (HCQ) can be added to this standard of care. OBJECTIVE: To evaluate the haemostatic safety of LDA and LMWH (medium to high prophylactic doses) during pregnancy and the puerperium in women with both full-blown obstetric antiphospholipid syndrome (OAPS) (Sydney criteria) and noncriteria - incomplete - OAPS. STUDY DESIGN: Retrospective/prospective multicentre observational study. Obstetric background, laboratory categories, delivery mode, antithrombotic regimens and bleeding complications were compared. SETTING: A total of 30 tertiary European hospitals. PATIENTS: Mainly, Caucasian/Arian pregnant women were included. Other ethnicities were minimally present. Women were controlled throughout pregnancy and puerperium. MAIN OUTCOME MEASURES: The primary end-point was to evaluate the number of major and minor haemorrhagic complications in this cohort of women. Neuraxial anaesthetic bleeding complications were particularly assessed. Secondly, we aimed to compare local/general bleeding events between groups. RESULTS: We studied 1650 women, of whom 1000 fulfilled the Sydney criteria of the OAPS and 650 did not (noncriteria OAPS). Data on antithrombotic-related complications were available in 1075 cases (65.15%). Overall, 53 (4.93%) women had bleeding complications, with 34 being considered minor (3.16%) and 19 major (1.76%). Neither obstetric complications nor laboratory categories were bleeding-related. Assisted vaginal delivery and caesarean section were related to local haemorrhage. Heparin doses and platelet count were not associated with major bleeding. CONCLUSIONS: LDA and medium to high prophylactic LMWH during pregnancy in women with full-blown OAPS/noncriteria OAPS are safe. A slight increase in bleeding risk was noted in instrumental deliveries. No women who underwent spinal or epidural anaesthesia suffered bleeding complications. No haemorrhage was observed in cases where HCQ was added to standard therapy.

Factors contributing to satisfaction with care in cancer outpatients.

OBJECTIVES: To evaluate satisfaction with care (SC) in cancer patients treated at a Spanish day hospital, to identify determinants of SC, and to assess the association between SC and quality of life (QL). METHODS: Cross-sectional study in which 119 patients undergoing outpatient chemotherapy completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), the Cancer Outpatient Satisfaction with Care questionnaire for chemotherapy (OUT-PATSAT35 CT), and an item on loyalty. Bivariate correlations between each subscale of the OUT-PATSAT35 CT and overall satisfaction, and between the subscales of OUT-PATSAT35 CT and QLQ-C30, were calculated. Multiple linear regression models were used to analyze determinants of patients' SC. RESULTS: Mean age was 62.5 years (SD 11.7), and 54.6% of the sample were female. Mean scores for SC were > 75 out of 100 on all OUT-PATSAT35 CT subscales, except environment. Overall satisfaction was higher than satisfaction in any subscale, and all patients would choose the same day hospital again. Correlation with overall satisfaction was moderate but statistically significant for all subscales. Patients treated for tumor recurrence and those undergoing palliative treatment manifested significantly lower overall satisfaction. Correlation between the EORTC QLQ-C30 and the OUT-PATSAT35 CT was not statistically significant, although patients with better health status reported higher satisfaction in several subscales. CONCLUSION: Patient-reported SC and loyalty towards the day hospital were high. Disease evolution and aim of treatment were determinants of overall satisfaction. The correlation between SC and QL was unclear. Some areas for improving care were noted.

Predicting hospital admission of patients with emergencies considered low priority according to assigned triage level. / Predicción de ingreso hospitalario en los pacientes con bajo nivel de prioridad de triaje atendidos en un servicio de urgencias.

OBJECTIVES: To develop a model to predict hospital admission of patients in cases assessed as nonurgent or semiurgent on emergency department triage. MATERIAL AND METHODS: Single-center observational study of a retrospective cohort. We included cases of patients older than 15 years whose emergency was classified as level IV-V according to the Andorran-Spanish triage model (MAT-SET, the Spanish acronym). Fourteen independent variables included demographic and care process items as well as vital signs. The dependent variable was hospital admission. The regression models were based on generalized estimating equations. RESULTS: A total of 53 860 episodes were included; 3430 patients (6.4%) were admitted. The median (interquartile range) age was 44.5 (31.1-63.9) years, and 54.1% were female. Vital signs were recorded in 19.3% of the episodes. The model that best predicted admission included the following variables: age > 84 years (adjusted odds ratio [aOR], 6.72; 95% CI, 5.26-8.60); male sex (aOR, 1.46; 95% CI, 1.28-1.66); referral from a primary care center (aOR, 1.94; 95% CI, 1.64-2.29); referral from another acute-care hospital (aOR, 11.22; 95% CI, 4.42-28.51); arrival by ambulance (aOR, 3.72; 95% CI, 3.16-4.40); revisit 72 hours (aOR, 2.15; 95% CI, 1.60-2.87); systolic blood pressure $ 150 mmHg (aOR, 0.83; 95% CI, 0.71-0.97); diastolic blood pressure 60 mmHg (aOR, 1.57; 95% CI, 1.25-1.98); axillary temperature > 37°C (aOR, 2.29; 95% CI, 1.91-2.74); heart rate > 100 beats/min (aOR, 1.65; 95% CI, 1.40-1.96); baseline oxygen saturation in arterial blood (SaO2) 93% (aOR, 2.66; 95% CI, 1.86-3.81); and SaO2 93%-95% (aOR, 1.70; 95% CI, 1.42-2.05). The area under the receiver operating characteristic curve for the model was 0.82 (95% CI; 95% CI, 0.80-0.83). CONCLUSION: The model predicts which patients are more likely to be admitted after their cases were initially considered nonurgent or semi-urgent on triage. Patients found to be at risk can then be given greater attention than others in the same triage level.

OBJETIVO: Desarrollar un modelo predictivo de ingreso hospitalario desde triaje de los pacientes atendidos en el servicio de urgencias hospitalario (SUH) con el nivel poco urgente-no urgente de prioridad de visita. METODO: Estudio observacional de cohortes retrospectivo unicéntrico. Se incluyeron los episodios de pacientes > 15 años con niveles IV-V MAT-SET atendidos en un SUH durante 2015. Se evaluaron 14 variables demográficas, datos de proceso y constantes vitales. La variable dependiente fue el ingreso hospitalario. Se utilizaron modelos de regresión basados en ecuaciones de estimación generalizadas. RESULTADOS: Se incluyeron 53.860 episodios, 3.430 (6,4%) ingresaron. La mediana de edad fue de 44,5 años (RIC 31,1-63,9), 54,1% mujeres. Un 19,3% de los episodios tenían registrados las constantes vitales (CV). El modelo con mayor capacidad predictiva incluía las siguientes variables: edad $ 85 años (ORa = 6,72; IC 95%: 5,26-8,60), sexo masculino (ORa = 1,46; IC 95% 1,28-1,66), procedencia de atención primaria (ORa = 1,94; IC 95% 1,64-2,29), de otro hospital de agudos (ORa = 11,22; IC 95% 4,42-28,51), llegada en ambulancia (ORa = 3,72; IC 95%:3,16-4,40), consulta previa a urgencias las 72 horas previas (ORa = 2,15; IC 95% 1,60-2,87), presión arterial sistólica $ 150 mmHg (ORa = 0,83; IC 95%:0,71-0,97), presión arterial diastólica 60 mmHg (ORa = 1,57; IC 95% 1,25-1,98), temperatura axilar > 37ºC (ORa = 2,29; IC 95% 1,91-2,74), frecuencia cardiaca > 100 latidos/minuto (ORa 1,65; IC 95% 1,40-1,96) y saturación basal de oxígeno 93% (ORa = 2,66; IC 95% 1,86-3,81) y 93-95% (ORa = 1,70; IC 95% 1,42-2,05). El área bajo la curva COR fue de 0,82 (IC 95% 0,80-0,83). CONCLUSIONES: Este modelo predictivo permitiría identificar desde el triaje a aquellos pacientes que, siendo poco urgentes o no urgentes, tienen mayor probabilidad de ingreso y darles una atención diferencial dentro del mismo nivel de prioridad.

Comparative Assessment of Two Strategies for Interpreting Tumor Markers in Ascitic Effusions.

BACKGROUND/AIM: There are two strategies for the interpretation of tumor markers (TM) in fluid effusions: i) high cut-off and ii) fluid/serum ratio (F/S) and low cut-off. The objective of this study is to compare these two strategies and to determine whether diagnostic accuracy improves by the identification of possible false positives using Adenosine deaminase (ADA), C reactive protein (CRP) and % of polymorphonuclear cells (%PN). PATIENTS AND METHODS: We studied 157 ascitic fluids, 74 of which were malignant. ADA, CRP and %PN were determined in ascitic fluid, and Carcinoembryonic antigen (CEA), Cancer antigen 72-4 (CA72-4), Cancer antigen CA19-9 and Cancer antigen 15-3 (CA15-3) in both fluid and serum. RESULTS: The strategy of high cut-off showed 59.5% sensitivity at 100% specificity. The F/S strategy showed 75.7% sensitivity at 95.2% specificity. Subclassifying cases with ADA, CRP and %PN negative showed 67.5% sensitivity at 100% specificity for high cut-off and for the F/S strategy was 81.7% sensitivity at 98.7% specificity. CONCLUSION: The strategy of F/S with negative ADA, CRP and %PN allow the best interpretation for TM in the ascitic fluid.

Effectiveness of a self-management programme in the treatment of antivitamin K oral anticoagulants. A feasibility study. / Eficacia de un programa de autocontrol en el tratamiento con anticoagulantes orales antivitamina K. Estudio de factibilidad.

BACKGROUND AND OBJECTIVES: To compare the efficacy of a self-monitoring programme vs. the conventional method used before the intervention in maintaining the international normalised ratio (INR) in the therapeutic range in patients receiving oral anticoagulants, as well as complications, quality of life and the time invested in the tests. PATIENTS AND METHODS: Pre-pospilot and feasibility study. The study included 15 patients over the age of 18 years who had been attending the monitoring programme for more than 6months. In the pre phase, patients performed the tests and follow-up in the outpatient clinic. After conducting an individual training session with each patient to teach them how to perform venipuncture, use the coagulometer, manage dosing tables and subsequent follow-up from the virtual clinic, we compared the percentage of in-range INR tests, complications, quality of life, and the time invested in performing the tests pre- (conventional) and post-intervention (intervention for self-monitoring). RESULTS: The percentage of INR tests in the therapeutic range was significantly higher in the post-phase than in the pre-phase (65.6% vs. 37.8%, p<.001). Likewise, the incidence of both minor and serious complications decreased in the post-phase (20% vs. 0%, and 6.7% vs. 0%, respectively). Finally, all 5dimensions of the quality of life questionnaire improved significantly, while the time invested decreased. CONCLUSIONS: In our experience, OAT self-monitoring is associated with a significant improvement in patient management, a reduction in the rate of complications, improved quality of life and timesaving.

Comparative study of obstetric antiphospholipid syndrome (OAPS) and non-criteria obstetric APS (NC-OAPS): report of 1640 cases from the EUROAPS registry.

OBJECTIVES: To compare clinical features, laboratory data and fetal-maternal outcomes between 1000 women with obstetric APS (OAPS) and 640 with aPL-related obstetric complications not fulfilling Sydney criteria (non-criteria OAPS, NC-OAPS). METHODS: This was a retrospective and prospective multicentre study from the European Registry on Obstetric Antiphospholipid Syndrome. RESULTS: A total of 1650 women with 5251 episodes, 3601 of which were historical and 1650 latest episodes, were included. Altogether, 1000 cases (OAPS group) fulfilled the Sydney classification criteria and 650 (NC-OAPS group) did not. Ten NC-OAPS cases were excluded for presenting thrombosis during follow-up. All cases were classified as category I (triple positivity or double positivity for aPL) or category II (simple positivity). Overall, aPL laboratory categories showed significant differences: 29.20% in OAPS vs 17.96% in NC-OAPS (P < 0.0001) for category I, and 70.8% in OAPS vs 82% in NC-OAPS (P < 0.0001) for category II. Significant differences were observed when current obstetric complications were compared (P < 0.001). However, major differences between groups were not observed in treatment rates, livebirths and thrombotic complications. In the NC-OAPS group, 176/640 (27.5%) did not fulfil Sydney clinical criteria (subgroup A), 175/640 (27.34%) had a low titre and/or non-persistent aPL positivity but did meet the clinical criteria (subgroup B) and 289/640 (45.15%) had a high aPL titre but did not fulfil Sydney clinical criteria (subgroup C). CONCLUSION: Significant clinical and laboratory differences were found between groups. Fetal-maternal outcomes were similar in both groups when treated. These results suggest that we could improve our clinical practice with better understanding of NC-OAPS patients.

Reliability and Diagnostic Accuracy of a New Vaginal Dynamometer to Measure Pelvic Floor Muscle Strength.

AIMS: Assess the intrarater and interrater reliabilities and diagnostic accuracy of a new vaginal dynamometer to measure pelvic floor muscle (PFM) strength in incontinent and continent women. METHODS: A test-retest reliability study including 152 female patients. EXCLUSION CRITERIA: history of urge urinary incontinence, prolapse of pelvic organ, pregnancy, previous urogynecological surgery, severe vaginal atrophy, or neurological conditions. The examination comprised digital assessment using the modified Oxford scale (MOS) and dynamometry measurements with a new prototype hand-held dynamometer. The MOS score ranges from 0 to 5: 0, no contraction; 1, flicker; 2, weak; 3, moderate; 4, good; 5, strong. Examinations were performed by a physiatrist, a physiotherapist and a midwife. The rest period between each rater measurement was 5 minutes. Assessment of intrarater and interrater reliability was calculated with the intraclass correlation coefficient. RESULTS: One hundred twenty-two incontinent women and 30 continent women were included. Scores between 0 and 2 in MOS were recorded in 72% of incontinent women versus 20% in continent patients (P < 0.001). Intrarater reliability of the dynamometer was 0.942 (95% confidence interval [CI], 0.920-0.958) and the interrater reliability was 0.937 (95% CI, 0.913-0.954). The analysis of variance analysis showed significant differences in PFM strength across digital assessment categories. The post-hoc analysis showed statistical differences between adjacent categories of MOS 1-2 and 2-3. The diagnostic accuracy showed an area under the curve of 0.82 (95% C,: 0.75-0.89), 0.87 (95% CI, 0.81-0.92), and 0.83 (95% CI, 0.77-0.90) for the physiatrist, midwife, and physiotherapist, respectively. CONCLUSIONS: The results obtained show a good reliability and validity of this new vaginal dynamometer to quantify PFM strength.

Diagnostic Accuracy of CYFRA21-1 in the Differential Diagnosis of Pleural Effusions.

BACKGROUND/AIM: Approximately 20% of pleural effusions are associated with cancer; about 50% require invasive procedures to perform diagnosis. Determination of the concentration of soluble cytokeratin 19-fragments (CYFRA21-1) may help identify patients with malignant effusions. However, pathologies other than cancer can increase its concentration. The identification of these possible false positives with routine tests CRP, ADA, % polymorphonuclear cells (PN) may improve diagnostic accuracy. This study aimed to determine the diagnostic accuracy of CYFRA21-1 in the detection of malignant pleural effusions and the possible false positives. MATERIALS AND METHODS: Analysis of CYFRA21-1, adenosine deaminase (ADA), C-reactive protein (CRP), and the percentage of polymorphonuclear leukocytes (PN%) in the fluid from 643 consecutive undiagnosed pleural effusions was performed. RESULTS: CYFRA21-1 showed 38.7% sensitivity and 97.3% specificity at 175 ng/ml cut-off. Effusions not suspicious of a false-positive showed 39.0% sensitivity and 98.2% specificity, while effusions suspicious of false positive showed lower sensitivity (36.4%) and specificity (95.0%). CONCLUSION: The diagnostic accuracy of CYFRA21-1 in pleural effusions can be improved by classification according to the possibility of false positives.

Inter-rater reliability of the digital palpation of pelvic floor muscle by the modified Oxford Grading Scale in continent and incontinent women. / Fiabilidad inter evaluador de la palpación digital de los músculos del suelo pélvico utilizando la escala modificada de Oxford graduada en mujeres continentes e incontinentes.

OBJECTIVE: The first choice treatment in stress urinary incontinence (SUI) is rehabilitation of the pelvic floor in order to improve muscle strength. However, no entirely reliable instruments for quantifying pelvic floor muscle (PFM) strength are currently available. Our aim was to test the inter-rater reliability of the Modified Oxford Scale (MOS) used as the gold standard for measuring PFM strength. METHODS: Test-retest reliability study. One hundred and twenty-two women with SUI and thirty continent women were recruited. Patients were excluded if they had a history consistent with pelvic organ prolapse, pregnancy, previous urogynaecological surgery, or neurological conditions. Bidigital palpation quantified by the MOS was carried out by three independent examiners. Each subject answered a two-part questionnaire: demographic and clinical characteristics and the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF). The Cohen's Kappa index with quadratic (Kw) weighting was used to assess the inter-rater agreement. RESULTS: 122 incontinent and 30 continent women were included. MOS ranged between 0 and 2 in 72.2% incontinent and 19.5% of continent women. The degree of agreement was substantial in the group of incontinent women (Kw between 0.73 and 0.81) and moderate in the group of continent women (Kw between 0.55 and 0.72). CONCLUSIONS: Our results suggest that the inter-observer reliability of MOS is improbable, especially in continent women.

OBJETIVO: El tratamiento de primera elección en la incontinencia urinaria de esfuerzo es la rehabilitación del suelo pélvico con el fin de mejorar la fuerza muscular. Sin embargo, actualmente no se dispone de instrumentos totalmente fiables para cuantificar la fuerza de la musculatura del suelo pélvico. Nuestro objetivo fue determinar la fiabilidad interobservador de la Escala de Oxford Modificada (MOS) utilizada como el patrón oro para medir la fuerza. MÉTODOS: Estudio de fiabilidad test-retest. Se reclutaron ciento veintidós mujeres con Incontinencia Urinaria de Esfuerzo y treinta mujeres continentes. Las pacientes fueron excluidas si presentaban: prolapso de órganos pélvicos, embarazo, cirugía uroginecológica previa, o enfermedades neurológicas. La palpación bidigital cuantificada con la Escala de Oxford Modificada fue realizada por tres examinadores independientes. Cada sujeto respondió a un cuestionario en dos partes: características demográficas y clínicas y el International Consultation on Incontinence Questionnaire-Forma abreviada (ICIQ-SF). Se utilizó el índice de Kappa de Cohen con ponderación cuadrática (Kw) para evaluar el acuerdo entre evaluadores. RESULTADOS: El MOS osciló entre 0 y 2 en el 72,2% de incontinentes y el 19,5% de las mujeres continentes. El grado de concordancia fue considerable en el grupo de mujeres incontinentes (Kw entre 0,73 y 0,81) y moderado en el grupo de mujeres continentes (Kw entre 0,55 y 0,72).CONCLUSIÓN: Nuestros resultados sugieren que la fiabilidad interobservador de la MOS es mejorable, especialmente en las mujeres continentes.