Assessing the Predictive Performance of Probabilistic Caries Risk Assessment Models: The Importance of Calibration.

Probabilistic caries risk assessment models (P-CRA), such as the Cariogram, are promising tools to planning treatments in order to control and prevent caries. The usefulness of these models for informing patients and medical decision-making depends on 2 properties known as discrimination and calibration. Current common assessment of P-CRA models, however, ignores calibration, and this can be misleading. The aim of this paper was to provide tools for a proper assessment of calibration of the P-CRA models and improve calibration when lacking. A combination of standard calibration tools (calibration plot, calibration in-the-large, and calibration slope) and 3 novel measures of calibration (the Calibration Index and 2 related metrics, E50 and E90) are proposed to evaluate if a P-CRA model is well calibrated. Moreover, an approach was proposed and validated using data from a previous follow-up study performed on children evaluated by means of a reduced Cariogram model; Platt scaling and isotonic regression were applied showing a lack of calibration. The use of the Cariogram overestimates the actual risk of new caries for forecast probabilities <0.5 and underestimates the risk for forecast probabilities >0.6. Both Platt scaling and isotonic regression were able to significantly improve the calibration of the reduced Cariogram model, preserving its discrimination properties. The average specificity and sensitivity for both Platt scaling and isotonic regression using the cut-off point p= 0.5 were >83 and their sum well exceeded 160. The benefits of the proposed calibration methods are promising, but further research in this field is required.

Prevalence of Abdominal Aortic Aneurysm in Men Aged 65-74 Years in a Metropolitan Area in North-East Spain.

BACKGROUND: A declining prevalence of AAA and a shift in the distribution towards the older population have been observed during the last decade in Europe. The aim was to estimate the current screening prevalence of AAA in men aged 65-74 years in a metropolitan area in north-east Spain and to identify associated risk factors. METHODS: A cross sectional prevalence study in men registered in L'Hospitalet Primary Healthcare Services (Barcelona, Spain) was performed. There were 619 randomly selected subjects (expected prevalence of aneurysm, 5%; accuracy of estimation, ±2%; loss to follow up, 30%). Exclusion criteria were life expectancy <1 year, limited quality of life, previous diagnosis of AAA, prior aorto-femoral surgery, and non-Caucasian. The following were measured: internal diameter of the infrarenal abdominal aorta using ultrasound, cardiovascular risk factors, personal (heart disease, stroke, peripheral vascular disease) and family history (AAA), physical examination, and blood tests. We estimated the prevalence and 95% confidence interval of AAA, and used logistic regression analysis to identify risk factors for AAA. RESULTS: Among the 651 individuals included in the analysis the prevalence of aneurysm was 2.30% (95% CI, 1.30-3.77%). In the regression analysis, AAA was associated with smoking (0-10, 11-20, or >20 cigarettes/day), diagnosis of myocardial infarction, and being taller than the median (165 cm). CONCLUSIONS: The current screening prevalence of AAA among men aged 65-74 years in a metropolitan area in north-east Spain is similar to that in northern Europe. Smoking, myocardial infarction, and height were associated with the presence of AAA.

The One Health approach for the management of an imported case of rabies in mainland Spain in 2013.

After more than 30 years without any reported cases of rabies in terrestrial carnivores in mainland Spain, an imported case was detected in June 2013 in Toledo. Although the infected dog was moved across different locations and had contact with humans and dogs, the incident was controlled within a few days. An epidemiological investigation was performed and rabies-free status in terrestrial carnivores in mainland Spain was restored six months after the incident. Key to the successful management of this case were the previous vaccination of susceptible animals in the affected area before the case was detected, the collaboration of different authorities in decision making, and the application of control measures according to national and international regulations and to the One Health concept.

[Translated article] Insertion of S1 iliosacral screws in the computed tomography room: An alternative to improve safety in the percutaneous management of posterior pelvic ring injuries.

INTRODUCTION: The main complication of percutaneous iliosacral screw fixation is implant malposition, which can lead to vascular and nerve damage. The anatomical variability of the sacrum can make screw insertion difficult under fluoroscopic guidance. Among the methods described to improve the accuracy of this technique, stands out the use of computed tomography (CT). The aim of this study is to compare the results of iliosacral screw insertion with fluoroscopy or CT navigation. METHODOLOGY: Retrospective cohort study of 66 iliosacral screws in 56 patients during 11 years. The screws were inserted with fluoroscopy in the operating room or with CT in the radiodiagnosis area. We collected data on patient characteristics, lesions, treatment, and clinical and radiological results. RESULTS: Forty-seven screws were inserted with fluoroscopy and 19 with CT. A percentage of 18.2 of screws perforated the S1 osseous corridor. All of them were inserted with fluoroscopy guidance (0 vs. 34%; p<0.01). Those operated with CT accumulated more sacral dysmorphism criteria than those operated with fluoroscopy (2.2 vs. 1.6; p=0.02). The S1 corridor on the axial CT view was narrower in those in whom perforation had occurred (18.8 vs. 21.0mm; p=0.02). Two cases with perforation developed S1 radiculalgia. Two endopelvic screws had to be removed. CONCLUSION: We advise the use of CT guidance for iliosacral screw insertion in patients with sacral dysmorphism or narrow S1 corridors in facilities where other navigation methods are not available.

Insertion of S1 iliosacral screws in the computed tomography room: An alternative to improve safety in the percutaneous management of posterior pelvic ring injuries. / Inserción de tornillos iliosacros S1 en la sala de tomografía computarizada. Una alternativa para mejorar la seguridad en el tratamiento percutáneo de las lesiones posteriores del anillo pélvico.

INTRODUCTION: The main complication of percutaneous iliosacral screw fixation is implant malposition, which can lead to vascular and nerve damage. The anatomical variability of the sacrum can make screw insertion difficult under fluoroscopic guidance. Among the methods described to improve the accuracy of this technique, stands out the use of computed tomography (CT). The aim of this study is to compare the results of iliosacral screw insertion with fluoroscopy or CT navigation. METHODOLOGY: Retrospective cohort study of 66 iliosacral screws in 56 patients during 11 years. The screws were inserted with fluoroscopy in the operating room or with CT in the radiodiagnosis area. We collected data on patient characteristics, lesions, treatment, and clinical and radiological results. RESULTS: Forty-seven screws were inserted with fluoroscopy and 19 with CT. A percentage of 18.2 of screws perforated the S1 osseous corridor. All of them were inserted with fluoroscopy guidance (0 vs. 34%; p<0.01). Those operated with CT accumulated more sacral dysmorphism criteria than those operated with fluoroscopy (2.2 vs. 1.6; p=0.02). The S1 corridor on the axial CT view was narrower in those in whom perforation had occurred (18.8 vs. 21.0mm; p=0.02). Two cases with perforation developed S1 radiculalgia. Two endopelvic screws had to be removed. CONCLUSION: We advise the use of CT guidance for iliosacral screw insertion in patients with sacral dysmorphism or narrow S1 corridors in facilities where other navigation methods are not available.

Growth rate as a prognostic factor in localized invasive cutaneous melanoma.

BACKGROUND: Melanoma is a tumour with a very variable progression. Whilst some melanomas grow slowly over many years, others can reach several millimetres in thickness in just a few weeks. Since melanoma is a visible superficial tumour, the information obtained from the clinical interview may be of use to calculate the speed of growth of the melanoma. OBJECTIVE: This study aims to assess the growth rate (GR) of melanomas and the association of this GR with various clinical and pathological factors and their usefulness as prognostic markers for localized invasive cutaneous melanomas. METHODS: The GR of melanomas was calculated as the ratio of tumour thickness to time of development, as obtained from the clinical history (in millimetres per month). RESULTS: Applying the GR calculation to patients with a localized melanoma showed a significant association between melanomas with a GR greater than 0.4 mm per month and an age of 65 years or over, male sex, nodular melanoma, tumour thickness, level of invasion, the presence of ulceration and a high mitotic index. As an independent prognostic factor for overall survival, the GR proved to be significant (P = 0.024). CONCLUSION: The GR of localized cutaneous melanomas may be a possible prognostic factor for survival. Additionally, rapid GR is associated with male patients more advanced in age at diagnosis, which suggests the need to assess new strategies for the early detection of these melanomas.

Mobile robotic platforms for the acoustic tracking of deep-sea demersal fishery resources.

Knowing the displacement capacity and mobility patterns of industrially exploited (i.e., fished) marine resources is key to establishing effective conservation management strategies in human-impacted marine ecosystems. Acquiring accurate behavioral information of deep-sea fished ecosystems is necessary to establish the sizes of marine protected areas within the framework of large international societal programs (e.g., European Community H2020, as part of the Blue Growth economic strategy). However, such information is currently scarce, and high-frequency and prolonged data collection is rarely available. Here, we report the implementation of autonomous underwater vehicles and remotely operated vehicles as an aid for acoustic long-baseline localization systems for autonomous tracking of Norway lobster (Nephrops norvegicus), one of the key living resources exploited in European waters. In combination with seafloor moored acoustic receivers, we detected and tracked the movements of 33 tagged lobsters at 400-m depth for more than 3 months. We also identified the best procedures to localize both the acoustic receivers and the tagged lobsters, based on algorithms designed for off-the-shelf acoustic tags identification. Autonomous mobile platforms that deliver data on animal behavior beyond traditional fixed platform capabilities represent an advance for prolonged, in situ monitoring of deep-sea benthic animal behavior at meter spatial scales.

Salbutamol tolerability and efficacy in patients with spinal muscular atrophy type II.

Spinal muscular atrophy (SMA) is an autosomal recessive disease caused by homozygous deletions or loss-of-function mutations in SMN1, which result in a degeneration of motor neurons in the spinal cord and brain stem. Even without a randomized placebo-controlled trial, salbutamol has been offered to patients with SMA in the neuromuscular clinics of most of hospitals for many years. We describe the response to salbutamol in 48 patients with SMA type II who were not taking any other medication. We investigate the changes over an eighteen-month period in motor functional scales and we analyze side effects and subjective response to treatment. Our results suggest that oral administration of salbutamol might be helpful in the maintenance of motor function in patients with SMA type II. An apparent beneficial effect was observed in functional scales of children under the age of 6, especially during the first 6 months of therapy. The majority of patients of all ages referred some kind of subjective positive effect associated with therapy intake. Salbutamol seemed safe and was well tolerated without serious side effects.

Calcium bioavailability from a calcium- and sulfate-rich mineral water, compared with milk, in young adult women.

Some mineral waters have a high calcium content and may contribute a significant part of the human daily requirements. Calcium bioavailability from a calcium- and sulfate-rich mineral water (CS-W) containing 11.2 mmol Ca/L (467 mg/L) was compared with that from milk in nine healthy young women. Calcium absorption was measured in the fasting state with a dual-label stable-isotope technique. Fractional absorption rates from milk and CS-W were 25.0 +/- 6.7% and 23.8 +/- 4.8% (means +/- SD), respectively, and did not differ significantly (P = 0.05). Urine was collected for 36 h after the administration of the oral stable isotope while the subjects consumed a controlled diet and a quantity of milk or CS-W providing 25 mmol (1000 mg) Ca. No significant difference was found in the excretion of calcium, nor in the excretion of the two stable isotopes. Mean urinary sulfate excretion was significantly increased by 35% when the CS-W was consumed. No significant correlation was found between 36-h urinary excretion of the intravenous calcium tracer and sulfate, sodium, or urine volume. Therefore, calcium from the CS-W was as well absorbed and retained as that from milk, and no calciuric effect of sulfate was found, showing that such mineral waters can be valuable dietary sources of calcium.

Failure of computerized impedance plethysmography in the diagnostic management of patients with clinically suspected deep-vein thrombosis.

Before a new diagnostic modality can be introduced in clinical medicine, the validity of both a normal and abnormal test result have to be assessed prospectively in an appropriate patient group. We have evaluated the clinical validity of a new computerized impedance plethysmography (CIP) in the diagnostic management of 381 consecutive patients with clinically suspected venous thrombosis. In patients with serially normal CIP results, the diagnosis of venous thrombosis was refuted and, consequently, they were not treated with anticoagulant therapy and all were followed up for a period of 6 months to estimate the occurrence of symptomatic venous thromboembolism. The study was prematurely terminated by the safety monitoring committee because of an unacceptably high incidence of confirmed venous thromboembolism (10 patients, 3.2%; 95% confidence interval: 1.6% to 6%), including 4 episodes of fatal pulmonary embolism. In a subsequent explanatory study using ultrasonography in 29 other symptomatic patients who had at least 2 repeated normal CIP test results, the failure of CIP to detect proximal vein thrombosis was confirmed in 4 patients (14%). The reasons for this failure are probably related to the use of a modified device to measure impedance in the CIP apparatus, resulting in a lower ability to separate patients without venous thrombosis from those with the disease. We concluded that CIP is insensitive for the detection of proximal vein thrombosis and, therefore, not clinically useful in the diagnostic management of patients with suspected venous thrombosis.

Contrast venography, the gold standard for the diagnosis of deep-vein thrombosis: improvement in observer agreement.

To determine whether the Rabinov-Paulin or the long-leg venography technique should be preferred in the diagnostic management of patients with clinically suspected deep-vein thrombosis, two independent experienced radiologists blindly assessed two different series of venograms of consecutive outpatients with clinically suspected deep-vein thrombosis. Venograms were obtained from two outpatient clinics of primary referral centres. In one centre the venograms were performed according to the technique of Rabinov and Paulin with the use of 100 ml of radiographic material and spot films of the calf, popliteal and more proximal veins. In the other centre, long-leg films were obtained after the administration of 150 ml of contrast material. The percentage venograms adjudicated as inadequate by at least one radiologist and inter-observer disagreement for both series were used as the main study outcome measures. Prior to the study, both radiologists agreed on the standardized criteria for a normal, abnormal and inadequate test result using a separate set of films. An inadequacy rate of 20% was found for the Rabinov-Paulin venography series (n = 123), whereas only 2% of the 126 long-leg films were inadequate for interpretation (p less than 0.001). The inter-observer diagreement for inadequacy, presence or absence of deep-vein thrombosis was 21% for the Rabinov and Paulin venograms and 4% for the long-leg films (kappa, 0.65 and 0.92; 95% confidence intervals: 0.53 to 0.77 and 0.84 to 0.99, respectively; p less than 0.002).(ABSTRACT TRUNCATED AT 250 WORDS)

A new computerized impedance plethysmograph: accuracy in the detection of proximal deep-vein thrombosis in symptomatic outpatients.

Because of the lack of specificity of the clinical diagnosis it is appropriate in patients with clinically suspected deep-vein thrombosis to apply an objective test before starting anticoagulant treatment. Impedance plethysmography is a highly accurate technique for the detection of proximal-vein thrombosis with a reported sensitivity and specificity of 93 and 97%, respectively. In all previous reported evaluations of impedance plethysmography an apparatus which was developed in 1971 was used. A new computerized impedance plethysmography, using a novel device to measure impedance, was blindly compared against venography in 443 consecutive outpatients with clinically suspected deep-vein thrombosis. In the first phase of the study the computerized impedance plethysmography test results of 242 symptomatic patients were used to develop a discriminant line. Subsequently, this discriminant line was validated in the second phase of the study in another 201 symptomatic patients. The combined sensitivity and specificity of these two phases for proximal-vein thrombosis was 91% [95% confidence interval (CI), 86 to 94%] and 94% and (95% CI, 90 to 96%), respectively, which compares favourably with impedance plethysmography. It is concluded that computerized impedance plethysmography is a simple, portable, non-invasive technique with a high accuracy for the detection of proximal vein thrombosis. However, before computerized impedance plethysmography can be used as the only test in the diagnosis of deep-vein thrombosis, the safety of withholding anticoagulant treatment to patients with repeated normal computerized test results should be assessed during long-term follow-up studies.

European Lymnaeidae (Mollusca: Gastropoda), intermediate hosts of trematodiases, based on nuclear ribosomal DNA ITS-2 sequences.

Freshwater snails of the family Lymnaeidae are of a great parasitological importance because of the very numerous helminth species they transmit, mainly trematodiases of large medical and veterinary impact. The present knowledge on the genetics of lymnaeids and on their parasite-host inter-relationships is far from being sufficient. The family is immersed in a systematic-taxonomic confusion. The necessity for a tool which enables species distinction and population characterization is evident. This paper aims to review the European Lymnaeidae basing on the second internal transcribed spacer ITS-2 of the nuclear ribosomal DNA. The ITS-2 sequences of 66 populations of 13 European and 1 North American lymnaeid species, including the five generic (or subgeneric) taxa Lymnaea sensu stricto, Stagnicola, Omphiscola, Radix and Galba, have been obtained. The ITS-2 proves to be a useful marker for resolving supraspecific, specific and population relationships in Lymnaeidae. Three different groupings according to their ITS-2 length could be distinguished: Radix and Galba may be considered the oldest taxa (370-406 bp lengths), and Lymnaea s. str., European Stagnicola and Omphiscola (468-491 bp lengths) the most recent, American Stagnicola and Hinkleyia being intermediate (434-450 bp lengths). This hypothesis agrees with the phylogeny of lymnaeids based on palaeontological data, chromosome numbers and radular dentition. ITS-2 sequences present a conserved central region flanked by two variable lateral regions corresponding to the 5' and 3' ends. The number of repeats of two microsatellites found in this conserved central region allows to differentiate Radix from all other lymnaeids. Phylogenetic trees showed four clades: (A) Lymnaea s. str., European Stagnicola and Omphiscola; (B) Radix species; (C) Galba truncatula; and (D) North American stagnicolines. ITS-2 results suggest that retaining Stagnicola as a subgenus of Lymnaea may be the most appropriate and that genus status for Omphiscola is justified. Radix shows a complexity suggesting different evolutionary lines, whereas G. truncatula appears to be very homogeneous. North American and European stagnicolines do not belong to the same supraspecific taxon; the genus Hinkleyia may be used for the American stagnicolines. Genetic distances and sequence differences allowed us to distinguish the upper limit to be expected within a single species and to how different sister species may be. S. palustris, S. fuscus and S. corvus proved to be valid species, but S. turricula may not be considered a species independent from S. palustris. Marked nucleotide divergences and genetic distances detected between different S. fuscus populations may be interpreted as a process of geographic differentiation developping in the present. Among Radix, six valid species could be distinguished: R. auricularia, R. ampla, R. peregra (=R. ovata;=R. balthica), R. labiata, R. lagotis and Radix sp. The information which the ITS-2 marker furnishes is of applied interest concerning the molluscan host specificity of the different trematode species. The phylogenetic trees inferred from the ITS-2 sequences are able to differentiate between lymnaeids transmitting and those non-transmitting fasciolids, as well as between those transmitting F. hepatica and those transmitting F. gigantica. The Fasciola specificity is linked to the two oldest genera which moreover cluster together in the phylogenetic trees, suggesting an origin of the Fasciola ancestors related to the origin of this branch. European Trichobilharzia species causing human dermatitis are transmitted only by lymnaeids of the Radix and Lymnaea s. str.-Stagnicola groups. Results suggest the convenience of reinvestigating compatibility differences after accurate lymnaeid species classification by ITS-2 sequencing. Similarly, ITS-2 sequencing would allow a step forward in the appropriate rearrangement of the actual systematic confusion among echinostomatids.

Changing features of proximal vein thrombosis over time.

Recently, the sensitivity of impedance plethysmography (IPG) for the diagnosis of acute deep-vein thrombosis (DVT) in symptomatic outpatients has been questioned. In order to verify whether a change in the venographic pattern of DVT has occurred over years, accounting for the decreased sensitivity of IPG, the authors compared two series of consecutive venograms demonstrating proximal DVT, performed between 1984-1988 (166 patients) and 1990-1992 (140 patients). They evaluated both the extension and the occlusiveness of deep-vein thrombi in the two series. Moreover, changes in the referral characteristics of patients were investigated. In the second series of venograms a significant decrease in thrombi extension, expressed by a lower prevalence of iliac vein thrombosis (29% versus 43%; P = 0.0074) was observed; moreover, a significant increase in the prevalence of nonocclusive thrombi (22% versus 8%; P = 0.0004) was also recorded in the second series when compared with the first. During the study period, among the referral characteristics of patients, the authors observed both a significant decrease in the prevalence of proximal DVT (from 31% to 24%; P < 0.01) and a slight and not statistically significant decrease in the median time elapsed between onset of symptoms and referral for objective testing (from eight and a half to seven days). In conclusion, proximal deep-vein thrombi are currently less extensive and occlusive than observed in the past. These results might depend on earlier referral of less symptomatic patients and might explain the recently reported decrease in IPG sensitivity for proximal DVT.

[Case of hemorrhagic pericarditis as the initial manifestation of pulmonary adenocarcinoma]. / Un caso di pericardite emorragica come prima manifestazione di un adenocarcinoma polmonare.

The Authors describe a case of pericardial involvement as the first sign of lung adenocarcinoma. Several evacuatory pericardiocentesis were required to treat recurrent hemorrhagic effusion. Pericardiectomy was finally carried out. The course of pericarditis was rapid: three and half months elapsed from the first symptoms of dyspnea to the death of patient.

Magnesium enrichment and distribution in plants.

Food products enriched with stable isotopes are used in nutrition to study the metabolic fate of nutrients in humans. This study reports on the labeling of green beans, white beans, soybeans and wheat with a stable isotope of magnesium (25Mg) obtained in greenhouse conditions for further studies on magnesium bioavailability. Soybean and green bean are the most efficient plant species to obtain large amounts of edible parts rapidly with a minimum loss of labeled Mg in other parts of the plants. The results obtained showed that a relatively high percentage of the magnesium found in seeds (grains/beans) can come from the redistribution of magnesium previously accumulated in other organs.

Computerized axial tomography in the evaluation of gynecologic pelvic masses.

The Authors retrospectively evaluate the advantages and limitations of CAT in 57 patients presenting suspected gynecologic pelvic masses. CAT showed great accuracy in identifying the presence or absence of the mass (only 3 false negatives and no false positive) whereas it diagnosed the nature of the lesion correctly only in 19 cases. In 41 cases the CAT provided clinically significant information adding to those of the gynecologic examination. Despite some limitations, CAT has proven to be a useful and accurate method to diagnose and evaluate suspected gynecologic masses before the surgical intervention.

The role of computerized axial tomography in the follow-up of patients with carcinoma of the ovary.

In order to assess the accuracy of CAT in the follow-up of the patients affected by ovarian carcinoma, we compared the results of this method to those of second-look laparotomy in 19 patients. In 16 out of 19 patients the CAT showed the presence or absence of disease correctly. There were 3 false negatives, caused by small diffuse peritoneal metastases, and no false positives. The results of this study show that CAT, though useful in studying the evolution of abdominal and pelvic carcinomas, cannot replace the surgical second-look in cases of ovarian cancers, due to the high incidence of false negatives.