[Evidence based guidelines. Diagnosis and management of Guillain-Barré syndrome in ten steps]. / Guía basada en la evidencia. Diagnóstico y manejo del síndrome de Guillain-Barré en diez pasos.

Guillain-Barré syndrome (GBS) is a rare, but potentially fatal, immune-mediated disease of the peripheral nerves and nerve roots that is usually triggered by infections. The incidence of GBS can therefore increase during outbreaks of infectious diseases, as was seen during the Zika virus epidemics in 2013 in French Polynesia and in 2015 in Latin America. Diagnosis and management of GBS can be complicated as its clinical presentation and disease course are heterogeneous, and no international clinical guidelines are currently available. To support clinicians, especially in the context of an outbreak, we have developed a globally applicable guideline for the diagnosis and management of GBS. The guideline is based on current literature and expert consensus, and has a ten-step structure to facilitate its use in clinical practice. We first provide an introduction to the diagnostic criteria, clinical variants and differential diagnoses of GBS. The ten steps then cover early recognition and diagnosis of GBS, admission to the intensive care unit, treatment indication and selection, monitoring and treatment of disease progression, prediction of clinical course and outcome, and management of complications and sequelae.

El síndrome de Guillain-Barré (SGB) es una enfermedad inmunológica del nervio periférico y las raíces nerviosas, poco frecuente, potencialmente mortal y que suele desencadenarse por infecciones. La incidencia del SGB puede aumentar durante el brote de enfermedades infecciosas, tal como se observó en las epidemias del virus Zika en la Polinesia Francesa en 2013 y en América Latina en 2015. El diagnóstico y el manejo clínico del SGB pueden ser complicados ya que su presentación y el curso de la enfermedad son heterogéneos, y actualmente no se cuenta con guías clínicas internacionales. Para respaldar a los médicos, especialmente en el contexto de un brote de una enfermedad infecciosa, hemos desarrollado una guía clínica aplicable en todo el mundo para el diagnóstico y el tratamiento del SGB. La guía se basa en literatura actualizada y el consenso de expertos, y tiene una estructura de diez pasos para facilitar su uso en la práctica clínica. Inicialmente, brindamos una introducción a los criterios de diagnóstico, variantes clínicas y diagnósticos diferenciales del SGB. Los diez pasos luego abordan el reconocimiento y el diagnóstico temprano del SGB, la admisión a la unidad de cuidados intensivos, indicación y selección de tratamiento, seguimiento y tratamiento de la progresión de la enfermedad, predicción del curso clínico, resultados y tratamiento de complicaciones y secuelas.

Guía basada en la evidencia. Diagnóstico y manejo del síndrome de Guillain-Barré en diez pasos / Evidence based guidelines. Diagnosis and management of Guillain-Barré syndrome in ten steps

Resumen El síndrome de Guillain-Barré (SGB) es una enfermedad inmunológica del nervio periférico y las raíces nerviosas, poco frecuente, potencialmente mortal y que suele desencadenarse por infecciones. La incidencia del SGB puede aumentar durante el brote de enfermedades infecciosas, tal como se observó en las epidemias del virus Zika en la Polinesia Francesa en 2013 y en América Latina en 2015. El diagnóstico y el manejo clínico del SGB pueden ser complicados ya que su presentación y el curso de la enfermedad son heterogéneos, y actualmente no se cuenta con guías clínicas internacionales. Para respaldar a los médicos, especialmente en el contexto de un brote de una enfermedad infecciosa, hemos desarrollado una guía clínica aplicable en todo el mundo para el diagnóstico y el tratamiento del SGB. La guía se basa en literatura actualizada y el consenso de expertos, y tiene una estructura de diez pasos para facilitar su uso en la práctica clínica. Inicialmente, brindamos una introducción a los criterios de diagnóstico, variantes clínicas y diagnósticos diferenciales del SGB. Los diez pasos luego abordan el reconocimiento y el diagnóstico temprano del SGB, la admisión a la unidad de cuidados intensivos, indicación y selección de tratamiento, seguimiento y tratamiento de la progresión de la enfermedad, predicción del curso clínico, resultados y tratamiento de complicaciones y secuelas.

Abstract Guillain-Barré syndrome (GBS) is a rare, but potentially fatal, immune-mediated disease of the peripheral nerves and nerve roots that is usually triggered by infections. The incidence of GBS can therefore increase during outbreaks of infectious diseases, as was seen during the Zika virus epidemics in 2013 in French Polynesia and in 2015 in Latin America. Diagnosis and management of GBS can be complicated as its clinical presentation and disease course are heterogeneous, and no international clinical guidelines are currently available. To support clinicians, especially in the context of an outbreak, we have developed a globally applicable guideline for the diagnosis and management of GBS. The guideline is based on current literature and expert consensus, and has a ten-step structure to facilitate its use in clinical practice. We first provide an introduction to the diag nostic criteria, clinical variants and differential diagnoses of GBS. The ten steps then cover early recognition and diagnosis of GBS, admission to the intensive care unit, treatment indication and selection, monitoring and treatment of disease progression, prediction of clinical course and outcome, and management of complications and sequelae.

Guillain-Barré syndrome during the Zika virus outbreak in Northeast Brazil: An observational cohort study.

OBJECTIVE: To determine the clinical phenotype of Guillain-Barré syndrome (GBS) after Zika virus (ZIKV) infection, the anti-glycolipid antibody signature, and the role of other circulating arthropod-borne viruses, we describe a cohort of GBS patients identified during ZIKV and chikungunya virus (CHIKV) outbreaks in Northeast Brazil. METHODS: We prospectively recruited GBS patients from a regional neurology center in Northeast Brazil between December 2014 and February 2017. Serum and CSF were tested for ZIKV, CHIKV, and dengue virus (DENV), by RT-PCR and antibodies, and serum was tested for GBS-associated antibodies to glycolipids. RESULTS: Seventy-one patients were identified. Forty-eight (68%) had laboratory evidence of a recent arbovirus infection; 25 (52%) ZIKV, 8 (17%) CHIKV, 1 (2%) DENV, and 14 (29%) ZIKV and CHIKV. Most patients with a recent arbovirus infection had motor and sensory symptoms (72%), a demyelinating electrophysiological subtype (67%) and a facial palsy (58%). Patients with a recent infection with ZIKV and CHIKV had a longer hospital admission and more frequent mechanical ventilation compared to the other patients. No specific anti-glycolipid antibody signature was identified in association with arbovirus infection, although significant antibody titres to GM1, GalC, LM1, and GalNAc-GD1a were found infrequently. CONCLUSION: A large proportion of cases had laboratory evidence of a recent infection with ZIKV or CHIKV, and recent infection with both viruses was found in almost one third of patients. Most patients with a recent arbovirus infection had a sensorimotor, demyelinating GBS. We did not find a specific anti-glycolipid antibody signature in association with arbovirus-related GBS.

Structural characterization and metal biosorptive activity of the major polysaccharide produced by Pseudomonas veronii 2E.

Pseudomonas veronii 2E, an autochthonous bacterium isolated from sediments associated to a high-polluted watershed, produces a complex matrix of exopolymers with carbohydrates as main components. In this work, four polysaccharides were isolated from the extracellular material. The major acidic polysaccharide named EPO2, was purified and its structure was elucidated using Matrix-assisted laser desorption/ionization and Electrospray ionization mass spectrometry, Infrared spectroscopy, Nuclear magnetic resonance spectroscopy and chemical treatments. This heteropolysaccharide consists in an α(1-4) glucan substituted with N-Acetylglucosamine residues and with a branching α-D-GlcpA-(1-3)-L-Fucp disaccharide. The biosorption capacity of EPO2 and of the whole exopolysaccharide to Pb(II), Zn(II), Cu(II) and Fe(II) was evaluated. EPO2 showed a remarkable sorption capacity for Fe(II) with an efficiency of 70% and for Zn(II) 39%. When the whole exopolysaccharide fraction was tested it showed a significantly lower metal sorption ability than purified EPO2 suggesting the involvement of the distinct acidic branching disaccharide in this interaction.

Problemas gastrointestinales, nutricionales, endocrinológicos y de microbiota en el trastorno del espectro autista / Gastrointestinal, nutritional, endocrine, and microbiota conditions in autism spectrum disorder

Los problemas médicos gastrointestinales, nutricionales, metabólicos, endocrinológicos y de microbiota en los pacientes pediátricos con diagnóstico de trastorno del espectro autista (TEA) son parte de los problemas médicos concomitantes al diagnóstico. La prevalencia alcanza a más del 91 % en el caso de los problemas gastrointestinales, hasta el 89 % para los nutricionales y metabólicos, más del 50 % de disfunción tiroidea y hasta el 100 % para los relacionados con la microbiota.Es urgente actualizar la práctica médica para incluir la evaluación, testeo, diagnóstico y tratamiento de estos problemas médicos concomitantes al diagnóstico de TEA en la población pediátrica, adolescente y adulta. El tratamiento riguroso de dichos problemas genera cambios positivos en la calidad de vida y en la sintomatología bajo la cual el TEA se diagnostica en muchos casos. Debe basarse en evidencia científica de alta calidad, con control y cuidado médico adecuado

Gastrointestinal, nutritional, metabolic, endocrine, and microbiota medical problems in pediatric patients diagnosed with autism spectrum disorder (ASD) are some of the coexisting medical conditions in ASD diagnosis. Their prevalence reaches more than 91 % for gastrointestinal problems, up to 89 % for nutritional and metabolic disorders, more than 50 % for thyroid dysfunction, and up to 100 % for microbiota-related conditions.There is an urgency for medical practice to be updated and to include the assessment, testing, diagnosis, and treatment of these coexisting medical conditions in ASD diagnosis in the pediatric, adolescent, and adult population. A strict management of such conditions results in positive changes in the quality of life and symptoms based on which ASD is diagnosed many times. It should be based on high-quality scientific evidence with an adequate medical care and control

Gastrointestinal, nutritional, endocrine, and microbiota conditions in autism spectrum disorder. / Problemas gastrointestinales, nutricionales, endocrinológicos y de microbiota en el trastorno del espectro autista.

Gastrointestinal, nutritional, metabolic, endocrine, and microbiota medical problems in pediatric patients diagnosed with autism spectrum disorder (ASD) are some of the coexisting medical conditions in ASD diagnosis. Their prevalence reaches more than 91 % for gastrointestinal problems, up to 89 % for nutritional and metabolic disorders, more than 50 % for thyroid dysfunction, and up to 100 % for microbiota-related conditions. There is an urgency for medical practice to be updated and to include the assessment, testing, diagnosis, and treatment of these coexisting medical conditions in ASD diagnosis in the pediatric, adolescent, and adult population. A strict management of such conditions results in positive changes in the quality of life and symptoms based on which ASD is diagnosed many times. It should be based on high-quality scientific evidence with an adequate medical care and control.

Los problemas médicos gastrointestinales, nutricionales, metabólicos, endocrinológicos y de microbiota en los pacientes pediátricos con diagnóstico de trastorno del espectro autista (TEA) son parte de los problemas médicos concomitantes al diagnóstico. La prevalencia alcanza a más del 91 % en el caso de los problemas gastrointestinales, hasta el 89 % para los nutricionales y metabólicos, más del 50 % de disfunción tiroidea y hasta el 100 % para los relacionados con la microbiota. Es urgente actualizar la práctica médica para incluir la evaluación, testeo, diagnóstico y tratamiento de estos problemas médicos concomitantes al diagnóstico de TEA en la población pediátrica, adolescente y adulta. El tratamiento riguroso de dichos problemas genera cambios positivos en la calidad de vida y en la sintomatología bajo la cual el TEA se diagnostica en muchos casos. Debe basarse en evidencia científica de alta calidad, con control y cuidado médico adecuado.

Infrared spectroscopy with multivariate analysis to interrogate the interaction of whole cells and secreted soluble exopolimeric substances of Pseudomonas veronii 2E with Cd(II), Cu(II) and Zn(II).

Extracellular polymeric substances (EPS) are bacterial products associated to cell wall or secreted to the liquid media that form the framework of microbial mats. These EPS contain functional groups as carboxyl, amino, hydroxyl, phosphate and sulfhydryl, able to interact with cations. Thus, EPS may be considered natural detoxifying compounds of metal polluted waters and wastewaters. In this work Attenuated Total Reflectance-Fourier Transform Infrared spectroscopy (ATR-FTIR) in combination with multivariate analysis (Principal Component Analysis-PCA-) were used to study the interaction of Cd(II), Cu(II) and Zn(II) and Pseudomonas veronii 2E cells, including bound EPS and cell wall, and its different soluble EPS fractions, previously characterized as Cd(II) ligands of moderate strength. Amino groups present in exopolysaccharide fraction were responsible for Zn(II) and Cu(II) complexation, while carboxylates chelated Cd(II). In lipopolysaccharide fraction, phosphoryl and carboxyl sites were involved in Cd(II) and Cu(II) binding, while Zn(II) interacted with amino groups. Similar results were obtained from cells. These studies confirmed that FTIR-PCA is a rapid analytical tool to provide valuable information regarding the functional groups in biomolecules related to metal interaction. Moreover, a discrimination and identification of functional groups present in both EPS and cells that interacted with Cd(II), Zn(II) and Cu(II) was demonstrated.

Diagnosis and management of Guillain-Barré syndrome in ten steps.

Guillain-Barré syndrome (GBS) is a rare, but potentially fatal, immune-mediated disease of the peripheral nerves and nerve roots that is usually triggered by infections. The incidence of GBS can therefore increase during outbreaks of infectious diseases, as was seen during the Zika virus epidemics in 2013 in French Polynesia and 2015 in Latin America. Diagnosis and management of GBS can be complicated as its clinical presentation and disease course are heterogeneous, and no international clinical guidelines are currently available. To support clinicians, especially in the context of an outbreak, we have developed a globally applicable guideline for the diagnosis and management of GBS. The guideline is based on current literature and expert consensus, and has a ten-step structure to facilitate its use in clinical practice. We first provide an introduction to the diagnostic criteria, clinical variants and differential diagnoses of GBS. The ten steps then cover early recognition and diagnosis of GBS, admission to the intensive care unit, treatment indication and selection, monitoring and treatment of disease progression, prediction of clinical course and outcome, and management of complications and sequelae.

Humanism in medicine: The critical role of pediatricians in autism spectrum disorder. / Humanismo en medicina: El rol crucial del pediatra en el trastorno del espectro autista.

In this article, we describe the importance of coexisting medical problems in the diagnosis of autism spectrum disorder (ASD). It is worth noting the role of pediatricians as health care providers trained to assess, test, diagnose, and treat such conditions during childhood. The population diagnosed with ASD is systemically vulnerable. ASD is the name given to a group of symptoms resulting from a systemic, dynamic, chronic encephalopathy according to the model proposed by Martha Herbert, M.D. (Harvard, USA). Based on this model, we may describe the circumstances of patients' families who, in Argentina, are unable to find answers on the coexisting medical problems in the diagnosis of ASD according to the psychoanalytic, genetic, and neurodiversity models. It is necessary to review current models in the setting of humanism in medicine because, so far, results have not been as expected.

Este artículo presenta la importancia de los problemas médicos concomitantes al diagnóstico del trastorno del espectro autista (TEA). Se resalta el rol del pediatra como el profesional médico preparado para evaluar, testear, diagnosticar y tratar estos problemas en la niñez. La población con diagnóstico de TEA es vulnerable sistémicamente. TEA es el nombre dado a una sintomatología emergente de una encefalopatía crónica, dinámica y sistémica según el modelo de la doctora Martha Herbert (Harvard, EE. UU.). Basados en este, se plantea la situación de las familias de los pacientes, en la Argentina, que no encuentran respuestas sobre los problemas médicos concomitantes al diagnóstico del TEA con los modelos: psicoanalítico, genético y de las neurodiversidades. Se establece la necesidad de revisar los modelos vigentes, en el marco del humanismo en medicina, debido a que los resultados no son los esperados.

Chemical characterization and ligand behaviour of Pseudomonas veronii 2E siderophores.

Siderophores are low-molecular weight ligands secreted by bacteria as a survival strategy in Fe(III)-lacking environments. They bind not only Fe(III), but Co(II), Zn(II), Mn(II), Ni(II), Ga(III) as a detoxification alternative. The synthesis, purification and characterization of siderophores produced by Pseudomonas veronii 2E were evaluated to be applied in future environmental technologies. Optimal production was obtained in Fe(III)-free M9-succinate at 25 °C, 40 h and pH 6.9. Siderophores were chemically characterized as hydroxamate and catechol mixed-type. Spectroscopic analysis indicated their belonging to the pyoverdine family, behaving as ligand to Cd(II), Zn(II), Cu(II), Ni(II) and Cr(III), which promoted siderophoregenesis during growth. Siderophore-Cd(II) complexation was studied by electrochemical monitored titration revealing one family of moderate-strength binding sites. Mass spectral analysis evidenced the secretion of a variety of molecules (molecular mass ca.1200 u). Non pathogenic Pseudomonas veronii 2E siderophores represent a safe alternative for the concrete application of environmental technologies and clinical procedures.

Increase of reactive oxygen species in different tissues during lipopolysaccharide-induced fever and antipyresis: an electron paramagnetic resonance study.

Fever is a regulated increase in body temperature and a component of the acute-phase response, triggered mainly after the invasion of pathogens in the body. Reactive oxygen species (ROS) are generated during the physiological and pathological processes, and can act as both signalling molecules as well as promoters of oxidative stress. Male Wistar rats, pretreated with oral doses of acetaminophen, celecoxib, dipyrone, or ibuprofen 30 min before an intravenous lipopolysaccharide (LPS) or sterile saline injection, showed a reduced febrile response in all animals tested. The formation of ROS in the fresh blood, liver, brown adipose tissue (BAT), and hypothalamus of febrile and antipyretic-treated animals was assessed by electron paramagnetic resonance using the spin probe 1-hydroxy-3-methoxycarbonyl-2,2,5,5-tetramethylpyrrolidine (CMH). While the CM• concentrations remained unaltered in the blood samples examined 5 h after the induction of fever, we found increased CM• levels in the liver (in µM, saline: 290 ± 42; LPS: 512 ± 34), BAT (in µM, saline: 509 ± 79, LPS: 855 ± 79), and hypothalamus (in µM, saline: 292 ± 35; LPS: 467 ± 8) at the same time point. Importantly, none of the antipyretics were seen to alter the CM• accumulation profile. Data from this study suggest that there is an increased formation of ROS in the different tissues during fever, which may cause oxidative stress, and that the antipyretics tested do not interfere with ROS production.

The role of endoscopic ultrasound in a case of lung cancer with jaundice.

Lung cancer is one of the major causes of death in the world. Small cell carcinoma is the most aggressive type and can spread rapidly. The association of a small cell carcinoma with hepatic hilar metastasis and biliary obstruction is rare. Endoscopic ultrasound allows the aspiration of a cytology sample from adenopathies for diagnostic purpose. We present the case of a patient with lung cancer, with lymph node metastasis to the hepatic hilum and extrinsic biliary tree compression. Endoscopic ultrasound allowed the definitive diagnosis of hepatic hilar metastasis of a lung small cell carcinoma. To the author's knowledge it was the first time that endoscopic ultrasound was used for the diagnosis of hepatic hilar lymph node metastasis of lung cancer.

Burkholderia cepacia lipase: A versatile catalyst in synthesis reactions.

The lipase from Burkholderia cepacia, formerly known as Pseudomonas cepacia lipase, is a commercial enzyme in both soluble and immobilized forms widely recognized for its thermal resistance and tolerance to a large number of solvents and short-chain alcohols. The main applications of this lipase are in transesterification reactions and in the synthesis of drugs (because of the properties mentioned above). This review intends to show the features of this enzyme and some of the most relevant aspects of its use in different synthesis reactions. Also, different immobilization techniques together with the effect of various compounds on lipase activity are presented. This lipase shows important advantages over other lipases, especially in reaction media including solvents or reactions involving short-chain alcohols.

Autoimmune Hepatitis and Autoimmune Hepatitis Overlap With Sclerosing Cholangitis: Immunophenotype Markers in Children and Adolescents.

OBJECTIVE: The pathophysiology of autoimmune hepatitis (AIH) may involve the activation of immune cells and changes in the expression of cellular markers. The aim of the present study was to characterize the immunophenotype markers of lymphocytes and monocytes in the peripheral blood of children and adolescents with type 1 AIH and AIH overlap with sclerosing cholangitis (overlap syndrome [OS]). METHODS: This is a cross-sectional study of 20 children and adolescents diagnosed with type 1 AIH and 19 with OS. Fifteen healthy subjects were included as controls. Flow cytometric analysis was used to identify markers of inflammation and autoimmunity. RESULTS: The total number of CD4 T cells was higher in the AIH patients compared with the controls. The number of CD4 T cells expressing CCR3 and CD28 was higher in the AIH group than in the control group. CD45RO was more highly expressed in the AIH group, whereas CD45RA was more highly expressed in the OS group. In regard to CD8 T lymphocytes, the CCR3 expression was higher in both groups of patients. Patients with OS had the highest expression of CD45RA and CD25. In monocytes, human leukocyte antigen DR (HLA-DR) was less expressed in both groups of patients. CONCLUSIONS: Complex phenotype features may be involved in the pathophysiology of AIH, accounting for changes in immune system regulation mechanisms. In conclusion, even after good response to treatment, patients still have immune activity signals at the cellular level.

Emprego de Túnica albugínea heteróloga ovina como reforço de parede abdominal em ratos / Employment of ovine heterologous Tunic albuginea as abdominal wall reinforcement in rats

Hérnias são umas das afecções que mais acometem os pequenos e grandes animais, podendo ter origem traumática ou não. Estas afecções, geralmente, necessitam de um reparo cirúrgico o mais rápido possível, devido ao fato de suas consequências poderem levar o animal ao óbito. Alguns estudos têm avaliado o comportamento da túnica albugínea como biomaterial de enxertia para reforço de parede abdominal, obtendo resultados favoráveis. O presente trabalho tem como objetivo avaliar o comportamento do enxerto de túnica albugínea ovina na parede abdominal de ratos. Foram selecionados 30 ratos da raça Wistar, os quais foram divididos em 2 grupos de 15 animais, sendo um grupo controle (C), um grupo teste (TA), onde os animais receberam reforço de parede abdominal com túnica albugínea ovina. Cada grupo foi dividido em três subgrupos contendo cinco animais, que foram submetidos à eutanásia nos dias 7, 21 e 42. O material coletado foi submetido a análises macroscópicas e histopatológicas a fim de afirmar a aplicabilidade do material e propor a utilização da túnica albugínea heteróloga como material de enxertia para a reconstrução da parede abdominal. Nos animais do grupo TA observou-se maior infiltrado inflamatório, neovascularização, deposição de colágeno e fibrose do que nos animais do grupo controle, concluindo assim que a túnica albugínea ovina é um biomaterial que funciona como substrato e promove uma precocidade da cicatrização de parede abdominal de ratos.

Hernias are one of the infections that most affect small and large animals, and may have traumatic origin or not. These conditions usually require a surgical repair as soon as possible, due to the fact that its consequences can lead the animal to death. Some studies have evaluated the behavior of the Tunica albuginea as a biomaterial for grafting abdominal wall reinforcement, obtaining favorable results. This study aims to evaluate the ovine Tunica albuginea graft behavior in the abdominal wall of rats. We selected 30 Wistar rats, which were divided into 2 groups of 15 rats, with a control group (C) and a test group (TA) where the rats received abdominal wall reinforcement with ovine Tunica albuginea. Each group was divided into three subgroups with five rats that were sacrificed on days 7, 21 and 42. The collected material was submitted to macroscopic and histopathological analysis to affirm the suitability of the material and propose the use of heterologous Tunica albuginea as grafting material for the reconstruction of the abdominal wall. In the TA group there was a higher inflammatory infiltration, neovascularization and collagen deposition and fibrosis than in group control, thus concluding that the ovine Tunica albuginea is a biomaterial that acts as substrate and promotes precocity of the abdominal wall healing of rats.

Quantification of immobilized Candida antarctica lipase B (CALB) using ICP-AES combined with Bradford method.

The aim of this manuscript was to study the application of a new method of protein quantification in Candida antarctica lipase B commercial solutions. Error sources associated to the traditional Bradford technique were demonstrated. Eight biocatalysts based on C. antarctica lipase B (CALB) immobilized onto magnetite nanoparticles were used. Magnetite nanoparticles were coated with chitosan (CHIT) and modified with glutaraldehyde (GLUT) and aminopropyltriethoxysilane (APTS). Later, CALB was adsorbed on the modified support. The proposed novel protein quantification method included the determination of sulfur (from protein in CALB solution) by means of Atomic Emission by Inductive Coupling Plasma (AE-ICP). Four different protocols were applied combining AE-ICP and classical Bradford assays, besides Carbon, Hydrogen and Nitrogen (CHN) analysis. The calculated error in protein content using the "classic" Bradford method with bovine serum albumin as standard ranged from 400 to 1200% when protein in CALB solution was quantified. These errors were calculated considering as "true protein content values" the results of the amount of immobilized protein obtained with the improved method. The optimum quantification procedure involved the combination of Bradford method, ICP and CHN analysis.

Validation of two US risk scores for percutaneous coronary intervention in a single-center Portuguese population of patients with acute coronary syndrome.

INTRODUCTION: New scores have been developed and validated in the US for in-hospital mortality risk stratification in patients undergoing coronary angioplasty: the National Cardiovascular Data Registry (NCDR) risk score and the Mayo Clinic Risk Score (MCRS). We sought to validate these scores in a European population with acute coronary syndrome (ACS) and to compare their predictive accuracy with that of the GRACE risk score. METHODS: In a single-center ACS registry of patients undergoing coronary angioplasty, we used the area under the receiver operating characteristic curve (AUC), a graphical representation of observed vs. expected mortality, and net reclassification improvement (NRI)/integrated discrimination improvement (IDI) analysis to compare the scores. RESULTS: A total of 2148 consecutive patients were included, mean age 63 years (SD 13), 74% male and 71% with ST-segment elevation ACS. In-hospital mortality was 4.5%. The GRACE score showed the best AUC (0.94, 95% CI 0.91-0.96) compared with NCDR (0.87, 95% CI 0.83-0.91, p=0.0003) and MCRS (0.85, 95% CI 0.81-0.90, p=0.0003). In model calibration analysis, GRACE showed the best predictive power. With GRACE, patients were more often correctly classified than with MCRS (NRI 78.7, 95% CI 59.6-97.7; IDI 0.136, 95% CI 0.073-0.199) or NCDR (NRI 79.2, 95% CI 60.2-98.2; IDI 0.148, 95% CI 0.087-0.209). CONCLUSION: The NCDR and Mayo Clinic risk scores are useful for risk stratification of in-hospital mortality in a European population of patients with ACS undergoing coronary angioplasty. However, the GRACE score is still to be preferred.

Predictive impact on medium-term mortality of hematological parameters in Acute Coronary Syndromes: added value on top of GRACE risk score.

BACKGROUND: Red Cell Distribution Width (RDW) prognostic value in patients with Acute Coronary Syndrome (ACS) has been well validated whereas that of Platelet Distribution Width (PDW) is less well known. OBJECTIVES: Investigate the incremental prognostic value, on top of GRACE risk score, of a new variable resulting from the combination of RDW and PDW. METHODS: Consecutive patients with ACS. Complete blood count, with RDW and PDW, was obtained. Primary endpoint was one-year all-cause mortality and Cox regression models were used to measure the influence of RDW and PDW on patients' survival time. A new combination categorical variable (RDW/PDW) was created with both discretized RDW and PDW and logistic regression models were used. Predictive value and discriminative ability of the model with GRACE risk score alone and of the model with inclusion of RDW/PDW was assessed. RESULTS: We included 787 patients. Hospital and one-year mortality rates were 5.1% and 7.8%, respectively. Both continuous RDW and PDW were independent predictors of death. The best cut-off for RDW was 13.9%, and 14.5% for PDW. Inclusion of RDW/PDW in a model with GRACE risk score improved the AUC from 0.81 (95% CI 0.75-0.86) to 0.84 (95% CI 0.79-0.90) (p=0.024) with an improvement in total NRI (56%) and IDI (0.048). CONCLUSIONS: Simple markers such as RDW and PDW can be useful in risk stratification of death after ACS. Combining both markers with GRACE risk score improved the predictive value for all-cause mortality and reduced the estimated risk of those who did not die.

Prognostic impact of admission blood glucose for all-cause mortality in patients with acute coronary syndromes: added value on top of GRACE risk score.

BACKGROUND: Abnormal glucose metabolism is a predictor of worse outcome after acute coronary syndrome (ACS). However, this parameter is not included in risk prediction scores, including GRACE risk score. We sought to evaluate whether the inclusion of blood glucose at admission in a model with GRACE risk score improves risk stratification. METHODS: Study of consecutive patients included in a single centre registry of ACS. Our primary endpoint was the occurrence of all-cause mortality at one-year follow-up. The ability of the two logistic regression models (GRACE risk score alone and in combination with blood glucose) to predict death was analysed. Continuous net reclassification improvement (NRI) and integrated discrimination improvement (IDI), with corresponding 95% confidence intervals (CIs), were also calculated. RESULTS: We included 2099 patients, with a mean age of 64 (SD=13) years, 69% males. In our sample, 55.1% presented with ST-segment elevation ACS and 13.1% in Killip class ≥ 2. Only 25% were known diabetic at admission. In-hospital mortality was 5.8% and 9.7% at one-year follow-up. The best cut-point for blood glucose was 160 mg/dl (sensitivity 62% and specificity 68%), and 35.2% of the patients had increased levels. This group was elderly, had more prevalence of cardiovascular risk factors, worse renal function and GRACE score as well as more frequently Killip class ≥2. Treatment was similar in both groups besides less frequent use of clopidogrel in high glycaemic patients. The hyperglycaemia group had higher one-year mortality (17.2% vs. 5.6%, p<0.001). Moreover, binary blood glucose remained a predictor of death independently of the GRACE risk score and the presence of diabetes (odds ratio (OR) 1.99, 95% CI 1.40-2.84, p<0.001). The inclusion of blood glucose, as a continuous variable, in a logistic regression model with GRACE score, increased the area under the ROC curve from 0.80 to 0.82 (p=0.018) as well as the goodness-of-fit and was associated with an improvement in both the NRI (37%) and the IDI (0.021), suggesting effective reclassification. CONCLUSIONS: A blood glucose level on admission ≥ 160 mg/dl is an independent predictor of mortality in medium-term follow-up. It offers an incremental predictive value when added to the GRACE risk score, although with a modest magnitude of improvement, probably due to the high predictive performance of the GRACE risk score alone.