New proposal to address mediation analysis interrogations by using genetic variants as instrumental variables.

The application of causal mediation analysis (CMA) considering the mediation effect of a third variable is increasing in epidemiological studies; however, this requires fitting strong assumptions on confounding bias. To address this limitation, we propose an extension of CMA combining it with Mendelian randomization (MRinCMA). We applied the new approach to analyse the causal effect of obesity and diabetes on pancreatic cancer, considering each factor as potential mediator. To check the performance of MRinCMA under several conditions/scenarios, we used it in different simulated data sets and compared it with structural equation models. For continuous variables, MRinCMA and structural equation models performed similarly, suggesting that both approaches are valid to obtain unbiased estimates. When noncontinuous variables were considered, MRinCMA presented, overall, lower bias than structural equation models. By applying MRinCMA, we did not find any evidence of causality of obesity or diabetes on pancreatic cancer. With this new methodology, researchers would be able to address CMA hypotheses by appropriately accounting for the confounding bias assumption regardless of the conditions used in their studies in different settings.

An illness-death multistate model to implement delta adjustment and reference-based imputation with time-to-event endpoints.

With a treatment policy strategy, therapies are evaluated regardless of the disturbance caused by intercurrent events (ICEs). Implementing this estimand is challenging if subjects are not followed up after the ICE. This circumstance can be dealt with using delta adjustment (DA) or reference-based (RB) imputation. In the survival field, DA and RB imputation have been researched so far using multiple imputation (MI). Here, we present a fully analytical solution. We use the illness-death multistate model with the following transitions: (a) from the initial state to the event of interest, (b) from the initial state to the ICE, and (c) from the ICE to the event. We estimate the intensity function of transitions (a) and (b) using flexible parametric survival models. Transition (c) is assumed unobserved but identifiable using DA or RB imputation assumptions. Various rules have been considered: no ICE effect, DA under proportional hazards (PH) or additive hazards (AH), jump to reference (J2R), and (either PH or AH) copy increment from reference. We obtain the marginal survival curve of interest by calculating, via numerical integration, the probability of transitioning from the initial state to the event of interest regardless of having passed or not by the ICE state. We use the delta method to obtain standard errors (SEs). Finally, we quantify the performance of the proposed estimator through simulations and compare it against MI. Our analytical solution is more efficient than MI and avoids SE misestimation-a known phenomenon associated with Rubin's variance equation.

Real-World Evidence of Tofacinitib in Ulcerative Colitis: Short-Term and Long-Term Effectiveness and Safety.

INTRODUCTION: The objective of this study was to assess the durability, short-term and long-term effectiveness, and safety of tofacitinib in ulcerative colitis (UC) in clinical practice. METHODS: This is a retrospective multicenter study including patients with UC who had received the first tofacitinib dose at least 8 weeks before the inclusion. Clinical effectiveness was based on partial Mayo score. RESULTS: A total of 408 patients were included. Of them, 184 (45%) withdrew tofacitinib during follow-up (mean = 18 months). The probability of maintaining tofacitinib was 67% at 6 m, 58% at 12 m, and 49% at 24 m. The main reason for tofacitinib withdrawal was primary nonresponse (44%). Older age at the start of tofacitinib and a higher severity of clinical activity were associated with tofacitinib withdrawal. The proportion of patients in remission was 38% at week 4, 45% at week 8, and 47% at week 16. Having moderate-to-severe vs mild disease activity at baseline and older age at tofacitinib start were associated with a lower and higher likelihood of remission at week 8, respectively. Of 171 patients in remission at week 8, 83 (49%) relapsed. The probability of maintaining response was 66% at 6 m and 54% at 12 m. There were 93 adverse events related to tofacitinib treatment (including 2 pulmonary thromboembolisms [in patients with risk factors] and 2 peripheral vascular thrombosis), and 29 led to tofacitinib discontinuation. DISCUSSION: Tofacitinib is effective in both short-term and long-term in patients with UC. The safety profile is similar to that previously reported.

Pain Behaviors Analyzed by Videorecording in Brain-Injured Patients Admitted to the Intensive Care Unit.

AIM: To describe and classify pain behaviors (facial and body) in brain-injured patients with a low level of consciousness before, during, and after the performance of painful and non-painful care procedures. METHODS: Facial behaviors and body movements in brain-injured patients were videotaped at rest, during the application of three care procedures (two painful and one non-painful), and 15 minutes after completion of these procedures. Each video recording was evaluated by expert evaluators blinded to each other. For each of the behaviors observed, all possible combinations between the three procedures and/or time were compared using the McNemar test. Effect size was measured by the difference in proportions using the Wilson score 95% confidence intervals. RESULTS: Twenty-seven patients were included. The mean (standard deviation) Glasgow Coma Score was 5.4 (1.9). A total of 33 behaviors (29 active, four neutral) were registered. Expression of behaviors was more common during the painful procedures compared with the other time points (non-painful procedures, baseline, and final evaluation). Inter-evaluator agreement was substantial (Kappa index >0.7) in more than 50% of the observed behaviors. CONCLUSIONS: In this study involving brain-injured patients with a low level of consciousness, facial, body, and ventilation-related behaviors were more common during painful procedures. Agreement between evaluators to detect the presence or absence of these behaviors was substantial. These findings underscore the need to develop pain assessment measures specific to this patient population.

Meta-DiSc 2.0: a web application for meta-analysis of diagnostic test accuracy data.

BACKGROUND: Diagnostic evidence of the accuracy of a test for identifying a target condition of interest can be estimated using systematic approaches following standardized methodologies. Statistical methods for the meta-analysis of diagnostic test accuracy (DTA) studies are relatively complex, presenting a challenge for reviewers without extensive statistical expertise. In 2006, we developed Meta-DiSc, a free user-friendly software to perform test accuracy meta-analysis. This statistical program is now widely used for performing DTA meta-analyses. We aimed to build a new version of the Meta-DiSc software to include statistical methods based on hierarchical models and an enhanced web-based interface to improve user experience. RESULTS: In this article, we present the updated version, Meta-DiSc 2.0, a web-based application developed using the R Shiny package. This new version implements recommended state-of-the-art statistical models to overcome the limitations of the statistical approaches included in the previous version. Meta-DiSc 2.0 performs statistical analyses of DTA reviews using a bivariate random effects model. The application offers a thorough analysis of heterogeneity, calculating logit variance estimates of sensitivity and specificity, the bivariate I-squared, the area of the 95% prediction ellipse, and the median odds ratios for sensitivity and specificity, and facilitating subgroup and meta-regression analyses. Furthermore, univariate random effects models can be applied to meta-analyses with few studies or with non-convergent bivariate models. The application interface has an intuitive design set out in four main menus: file upload; graphical description (forest and ROC plane plots); meta-analysis (pooling of sensitivity and specificity, estimation of likelihood ratios and diagnostic odds ratio, sROC curve); and summary of findings (impact of test through downstream consequences in a hypothetical population with a given prevalence). All computational algorithms have been validated in several real datasets by comparing results obtained with STATA/SAS and MetaDTA packages. CONCLUSION: We have developed and validated an updated version of the Meta-DiSc software that is more accessible and statistically sound. The web application is freely available at www.metadisc.es .

Avoiding collider bias in Mendelian randomization when performing stratified analyses.

Mendelian randomization (MR) uses genetic variants as instrumental variables to investigate the causal effect of a risk factor on an outcome. A collider is a variable influenced by two or more other variables. Naive calculation of MR estimates in strata of the population defined by a collider, such as a variable affected by the risk factor, can result in collider bias. We propose an approach that allows MR estimation in strata of the population while avoiding collider bias. This approach constructs a new variable, the residual collider, as the residual from regression of the collider on the genetic instrument, and then calculates causal estimates in strata defined by quantiles of the residual collider. Estimates stratified on the residual collider will typically have an equivalent interpretation to estimates stratified on the collider, but they are not subject to collider bias. We apply the approach in several simulation scenarios considering different characteristics of the collider variable and strengths of the instrument. We then apply the proposed approach to investigate the causal effect of smoking on bladder cancer in strata of the population defined by bodyweight. The new approach generated unbiased estimates in all the simulation settings. In the applied example, we observed a trend in the stratum-specific MR estimates at different bodyweight levels that suggested stronger effects of smoking on bladder cancer among individuals with lower bodyweight. The proposed approach can be used to perform MR studying heterogeneity among subgroups of the population while avoiding collider bias.

Longitudinal Analysis of Continuous Pulse Oximetry as Prognostic Factor in Neonatal Respiratory Distress.

OBJECTIVE: Analysis of longitudinal data can provide neonatologists with tools that can help predict clinical deterioration and improve outcomes. The aim of this study is to analyze continuous monitoring data in newborns, using vital signs to develop predictive models for intensive care admission and time to discharge. STUDY DESIGN: We conducted a retrospective cohort study, including term and preterm newborns with respiratory distress patients admitted to the neonatal ward. Clinical and epidemiological data, as well as mean heart rate and saturation, at every minute for the first 12 hours of admission were collected. Multivariate mixed, survival and joint models were developed. RESULTS: A total of 56,377 heart rate and 56,412 oxygen saturation data were analyzed from 80 admitted patients. Of them, 73 were discharged home and 7 required transfer to the intensive care unit (ICU). Longitudinal evolution of heart rate (p < 0.01) and oxygen saturation (p = 0.01) were associated with time to discharge, as well as birth weight (p < 0.01) and type of delivery (p < 0.01). Longitudinal heart rate evolution (p < 0.01) and fraction of inspired oxygen at admission at the ward (p < 0.01) predicted neonatal ICU (NICU) admission. CONCLUSION: Longitudinal evolution of heart rate can help predict time to transfer to intensive care, and both heart rate and oxygen saturation can help predict time to discharge. Analysis of continuous monitoring data in patients admitted to neonatal wards provides useful tools to stratify risks and helps in taking medical decisions. KEY POINTS: · Continuous monitoring of vital signs can help predict and prevent clinical deterioration in neonatal patients.. · In our study, longitudinal analysis of heart rate and oxygen saturation predicted time to discharge and intensive care admission.. · More studies are needed to prospectively prove that these models can helpmake clinical decisions and stratify patients' risks..

Impact of selection for birth weight variability on reproductive longevity: A mice model.

Uniformity, understood as a similar performance in relevant livestock traits, such as birth weight within the litter, is being included as one of the selection objectives in breeding programmes, especially for polytocous livestock species. A divergent selection experiment for birth weight within-litter variability in mice during 23 generations showed that homogeneous animals were better for litter size, survival and feed efficiency but less heavy than heterogeneous animals. The aim of this study was to compare the reproductive longevity in both divergent lines as time to the end of the reproductive period. Two generations from both lines with an initial number of 43 females and 43 males were mated one to one and stayed together to have consecutive parturitions until the end of the reproductive life. Females were discarded when the time elapsed from the last parturition was longer than 63 days. The time to the end of the reproductive period between both lines was compared by fitting a Cox proportional hazard regression model adjusting for line, generation and its interaction. The rate of parturitions in both lines was also compared using a Prentice-Williams-Peterson model adjusted for the same effects. The low variability line was associated with a higher parturition rate, e.g., adjusted hazard ratio was 2.93 (95% CI 2.17-3.94). The Cox model showed that the low variability females also presented benefits of time to the end of the reproductive period, with an adjusted hazard ratio of 0.26 (95% CI 0.16-0.41). The median of reproductive days was 55.50 in the high variability line whilst the median was 252.50 days for the low variability females. The homogeneous line presented important reproductive advantages suggesting higher robustness and animal welfare. Further research should confirm whether the findings presented here of a better performance in the low variability line could be properly applied to some livestock species.

Gender dysphoria: laparoscopic sigmoid vaginoplasty. Another utility of indocyanine green.

AIM: Gender dysphoria is the disagreement between the gender of birth and the one with which the patient identifies. For its management it is mandatory to have a multidisciplinary team. Gender confirmation surgery with penoscrotal skin flap is the procedure of choice, and a sigmoid vaginoplasty is a feasible alternative. The new technologies and the help of indocyanine green (ICG) fluorescence can help to guarantee a correct neovagina vascularization. The objective of this paper is to present the surgical technique of laparoscopic sigmoid vaginoplasty assisted by ICG. METHODS: We present two patients with gender dysphoria and a history of stricture of the penoscrotal skin flap vaginoplasty. We performed sigmoid vaginoplasty by the laparoscopic approach. We began the procedure with the mobilization and section of 30 cm of sigmoid colon, selective ligation of the vessels assisted by ICG, 180° sigmoid rotation, externalized on antiperistaltic position, construction of colovestibular anastomosis and promontory fixation. We finished the procedure with virtual ileostomy construction and drain placement. RESULTS: Patients recovered satisfactorily and were discharged on the seventh day after surgery without complications. CONCLUSION: Sigmoid vaginoplasty is a safe and feasible procedure. ICG has great value, contributing to the selective ligation of the vessels, allowing 180° sigmoid rotation and guaranteeing the irrigation of the neovagina.

The Relation between Drying Conditions and the Development of Volatile Compounds in Saffron (Crocus sativus).

Saffron is derived from the stigmas of the flower Crocus sativus L. The drying process is the most important post-harvest step for converting C. sativus stigmas into saffron. The aim of this review is to evaluate saffron's post-harvest conditions in the development of volatile compounds and its aroma descriptors. It describes saffron's compound generation by enzymatic pathways and degradation reactions. Saffron quality is described by their metabolite's solubility and the determination of picrocrocin, crocins, and safranal. The drying process induce various modifications in terms of color, flavor and aroma, which take place in the spice. It affects the aromatic species chemical profile. In the food industry, saffron is employed for its sensory attributes, such as coloring, related mainly to crocins (mono-glycosyl esters or di-glycosyl polyene).

Survival in Restless Legs Syndrome: An 11-Year Surveillance, Community-Based Population Study.

BACKGROUND: A growing body of evidence relates restless legs syndrome (RLS) to an increased risk of mortality attributable to both cerebrovascular and cardiovascular events. The aim was to investigate survival in patients with RLS. METHODS: This was an observational, retrospective longitudinal study of a cohort of patients followed up for 11 years. RLS was diagnosed by a physician using the International RLS Study Group criteria. Mortality was analyzed using age-standardized mortality ratios (SMR: observed/expected deaths) and Cox regression analysis. RESULTS: Vital status was studied in a cohort of 232 patients: 181 women (78%), 96 with RLS (41.4%) with a mean age at baseline of 49.8 ± 15.0 years and a mean RLS duration of 14.1 ± 1.9 years, and 136 non-RLS (58.6%) with a mean age of 51.3 ± 14.9 years. This RLS cohort was followed up for a period of 10.4 ± 2.0 years. As of September 2019, 17 (7.3%) patients died (6 with RLS, 6.3%), and the most frequent cause was oncological (66.7%). A total of 944 person-years of observations were available for survival analysis. RLS was not associated with increased mortality in adjusted Cox regression analysis (HR = 1.12, 95% CI: 0.40-3.15), and survival was similar to that expected for the general population (SMR = 0.61, 95% CI: 0.27-1.36). CONCLUSIONS: RLS seems not to be associated with increased mortality compared to the general population. Still, studies with prospective data collection with large samples are needed to study the long-term mortality risk factors in RLS cohorts.

Oculomotor deficits in children adopted from Eastern Europe.

AIM: We aim to assess oculomotor behaviour in children adopted from Eastern Europe, who are at high risk of maternal alcohol consumption. METHODS: This cross-sectional study included 29 adoptees and 29 age-matched controls. All of them underwent a complete ophthalmological examination. Oculomotor control, including fixation and saccadic performance, was assessed using a DIVE device, with eye tracking technology. Anthropometric and facial measurements were obtained from all the adopted children, to identify features of foetal alcohol spectrum disorders (FASD). Fixational and saccadic outcomes were compared between groups, and the effect of adoption and FASD features quantified. RESULTS: Oculomotor performance was poorer in adopted children. They presented shorter (0.53 vs 1.43 milliseconds in the long task and 0.43 vs 0.82 in the short task) and more unstable fixations (with a bivariate contour ellipse area of 27.9 vs 11.6 degree2 during the long task and 6.9 vs 1.3 degree2 during the short task) and slower saccadic reactions (278 vs 197 milliseconds). Children with sentinel finding for FASD showed the worst oculomotor outcomes. CONCLUSION: Children adopted from Eastern Europe present oculomotor deficits, affecting both fixation and saccadic skills. We highlight prenatal exposure to alcohol as the main cause for these deficits.

Application of the Behavioural Indicators of Pain Scale in patients with traumatic brain injury.

AIM: To develop and psychometrically test the Behavioural Indicators of Pain Scale (ESCID) in patients with traumatic brain injury (TBI). DESIGN: A prospective observational study to test the psychometric properties of the Behavioural Indicators of Pain Scale in patients with TBI. METHOD: A convenience sample of patients with TBI, who were non-communicative and using invasive mechanical ventilation was selected. Pain was evaluated by two observers who were blinded from each other. Assessments were performed at baseline via the performance of a painful procedure (aspiration of secretions) and a non-painful procedure (rubbing with a gauze). Assessments were repeated after application of procedures on days 1 and 6 of hospitalization in an intensive care unit. Data were collected between January-December 2016. RESULTS: About 134 patients were included in the study. Of these, 76.1% were men. The mean age of participants was 45.2 (SD 17.5) years. The pain score significantly increased during the painful procedure when compared with the baseline measure and non-painful procedure (p < .001). Patients displayed a greater number of pain-indicating behaviours during the painful procedure on day 6, compared with day 1 (p < .05). This finding coincided with a reduced level of sedation and a greater level of consciousness. CONCLUSION: The ESCID scale detects pain behaviours and discriminates among the different types of stimulation in patients with brain injury, who are uncommunicative and with mechanical ventilation, with good reliability. The ability for patients with brain injury to express behaviours is limited because of the low level of consciousness and the deep level of sedation. IMPACT: This research will have an impact on the practice of pain assessment in patients with brain injury, representing a first step to adapt the content of the ESCID.

MMRM vs joint modeling of longitudinal responses and time to study drug discontinuation in clinical trials using a "de jure" estimand.

In pre-marketing stages of drug development, trialists focus on drug efficacy rather than effectiveness, and observations collected after study drug discontinuation are excluded from the analysis, following the so-called "de jure" estimand. In this setting, mixed models for repeated measures (MMRM) are becoming the benchmark to analyze normally distributed longitudinal responses. We have compared the performance of MMRM against shared parameter models (SPM) that jointly fit the longitudinal response and time to study drug discontinuation. Our simulations have first confirmed that MMRM lead to biased treatment effect estimates when longitudinal and event processes are associated via latent shared parameters, especially if the relationship is heterogeneous across treatment groups. SPM produced unbiased estimates with SPM data but faced two important obstacles: (a) SPM led to considerable bias when treatment discontinuation and response were associated with models of the time-varying covariates (TVC) family, and (b) SPM were rather sensitive to the choice of the parameterization to model the relationship between longitudinal and time-to-event processes. When we simulated SPM data but used an incorrect equation to relate the random effects and time-to-event response, SPM led to a bigger bias than that seen with MMRM. We have finally evaluated a methodology to choose between MMRM and SPM consisting of expanding the MMRM density into the likelihood of both longitudinal and time-to-event data by plugging in the likelihood of a parametric TVC model. This approach allowed us to accurately select the optimal tool (MMRM or SPM) with sample sizes typical of phases 2b and 3.

Visual cognitive impairments in children at risk of prenatal alcohol exposure.

AIM: To evaluate the relationship between visoperception and anthropometric features related to prenatal alcohol exposure. METHODS: We compared two cohorts of infants aged between 5 and 18 years. Seventy-nine children, adopted from Eastern Europe, were included in the study group. The control group was formed by age and gender matched children born in Spain. All children underwent a full ophthalmologic assessment and standardised testing of visual cognitive skills. RESULTS: Adoptees presented worse visual motor and visual perceptual outcomes in all skills compared with control subjects, with statistically significant difference in test of visual perceptual skills (TVPS) global centile (50.3 vs 66.8; P = 0.001), spatial relationships (64.6 vs 81.9; P = 0.004) and visual figure-ground (52.1 vs 74.1; P = 0.002) tasks. Face recognition was as well significantly worse in adopted children (42.4 vs 57.1; P = 0.009). Twenty-one adopted children (26.6%) had sentinel finding for foetal alcohol spectrum disorders (FASD). Main facial features related to FASD correlated with visual cognitive outcomes. Of the adopted children, those diagnosed of FASD showed incrementally worse visual perceptual and visual motor outcomes (TVPS global centile = 36.86, P = 0.001; TVAS = 10.38, P = 0.002). CONCLUSION: Children adopted from eastern Europe are at increased risk of visual perceptual disabilities, especially those with sentinel findings of foetal alcohol syndrome disorders.

Structural, Physical, and Antifungal Characterization of Starch Edible Films Added with Nanocomposites and Mexican Oregano (Lippia berlandieri Schauer) Essential Oil.

The aim of this study was to evaluate the structural, physical, and antifungal characteristics of starch edible films added with nanocomposites and Mexican oregano (Lippia berlandieri Schauer) essential oil (EO). Starch edible films were formulated with Mexican oregano EO (0%, 1%, or 2% v/v) and bentonite or halloysite (2%). Physical properties such as L* (luminosity), hue, film thickness, and O2 and CO2 permeability were determined. Structural analysis was carried out via atomic force microscopy (AFM). Antifungal activity against Aspergillus niger, Fusarium spp., and Rhizopus spp. was evaluated. The addition of EO and nanocomposites reduced luminosity, providing color to the edible films. Film thickness increased through the addition of EO concentration. O2 and CO2 permeability was increased by bentonite/EO films, and for halloysite films, CO2 permeability decreased as EO concentration increased. The addition of EO with both nanocomposites shows an evident morphological change in film structure, decreasing pore density and increasing pore size. In general, Mexican oregano EO added to edible starch films has an adequate fungicidal effect. The most sensitive microorganism tested was A. niger. Edible films added with Mexican oregano EO and nanocomposites show better physical and antifungal properties due to an adequate structural change in the biopolymer matrix.

C-reactive protein expression in adipose tissue of children with acute appendicitis.

OBJECTIVE: The aim of this study is to gain insights into the role of visceral adipose tissue as a source of C-reactive protein (CRP) in acute inflammation and to explore the potential relationship of CRP expression with the severity of appendicitis. METHODS: A total of 20 pediatric patients undergoing appendectomy were included in the study. Patients were divided into two groups according to appendicitis severity (uncomplicated and complicated). CRP levels were measured in visceral fat samples by western blotting, as well as in serum by biochemical testing. RESULTS: CRP was found to be expressed in visceral adipose tissue. The adipose tissue of patients with complicated appendicitis showed significantly higher CRP levels (p = 0.002) compared to patients with uncomplicated appendicitis. These results mirrored the CRP values obtained in serum (p = 0.018). CONCLUSION: In childhood, visceral adipose tissue is a source of CRP in acute inflammation, and its expression is potentially associated with the severity of local inflammation.

Pancreatic stent insertion after an unintentional guidewire cannulation of the pancreatic duct during ERCP.

INTRODUCTION: the guidewire (GW) may enter the pancreatic duct during common bile duct (CBD) cannulation attempts in endoscopic retrograde cholangiopancreatography (ERCP). After GW passage into the pancreas, the most effective maneuver for CBD cannulation and pancreatitis prevention has not been determined. AIM: to study CBD cannulation and post-ERCP pancreatitis rates when a pancreatic stent is inserted after an unintentional GW cannulation of the pancreatic duct. MATERIAL AND METHODS: a retrospective analysis of patients undergoing ERCP for biliary drainage that were included prospectively into a database. After unintentional GW cannulation of the pancreatic duct, a straight 5-Fr and 4-cm long plastic stent was inserted. The stents had no internal flaps to facilitate expulsion. CBD cannulation attempts were made above the stent. A pancreatic sphincterotomy was performed in patients older than 60 years before stent insertion. RESULTS: a total of 46 pancreatic stents were inserted during 154 ERCP (29.8%) procedures. In the stent group, CBD cannulation was accomplished in 44/46 (95.6%) subjects. A total of 21/46 (45.6%) pancreatic sphincterotomies were performed. Only 1/46 (2.17%) mild pancreatitis cases were observed and most stents were spontaneously expelled. CONCLUSIONS: in this study, the CBD was eventually reached with the insertion of a plastic pancreatic stent after an unintentional GW passage into the pancreatic duct while attempting a CBD cannulation. No adverse events were observed following pancreatic stent insertion.

Pain Assessment in Mechanically Ventilated, Noncommunicative Severe Trauma Patients.

The aim of this study was to measure pain levels in noncommunicative patients with severe trauma who required tracheal suctioning and mobilization and to determine the utility of the Behavioral Indicators of Pain Scale (ESCID) in these cases. The pain scores for the procedures were recorded on Days 1, 3, and 6 of the patients' stay in the intensive care unit. These assessments were performed at 3 moments: before, during, and after the application of the procedures. Because of the longitudinal character of the study, data were fitted into a multivariate model using the Generalized Estimating Equations method. The sample of 124 patients comprised 77.4% males and 22.6% females with an average age of 45.93 (SD = 16.43) years. A significant increase (p < .01) in the ESCID score was observed during the application of the procedures that produced similar pain levels. Kappa coefficient value obtained for interobserver agreement of ESCID scale scores during the application of care procedures at the intervals being evaluated was greater than 0.84, which should be interpreted as almost perfect. The ESCID scores increased during 2 care procedures that are frequently carried out in intensive care units and indicated that they produced similar pain levels.

Relationship between polymorphisms in the CRP, LEP and LEPR genes and high sensitivity C-reactive protein levels in Spanish children.

BACKGROUND: We investigated the association of single nucleotide polymorphisms (SNPs) in the C-reactive protein (CRP), leptin (LEP) and leptin receptor (LEPR) genes with high sensitivity CRP (hs-CRP) levels in two independent cohorts of healthy Spanish children. METHODS: We measured hs-CRP levels in 646 6-8-year-old and 707 12-16-year-old children using a high-sensitivity C-Reactive Protein ELISA kit. Four SNPs in the CRP gene (rs1205, rs1130864, rs2794521 and rs1800947), one SNP in the LEP gene (rs7799039) and two SNPs in the LEPR (rs1137100 and rs1137101) gene were determined by TaqMan® allelic discrimination assays. RESULTS: The four CRP SNPs studied were significantly (p<0.05) associated with hs-CRP levels in both cohorts. Furthermore, two common CRP haplotypes (constructed using the SNPs in order: rs1205, rs1130864, rs1800947, rs2794521) ACGA and GCGG were associated with significantly lower CRP levels (p<0.05) at both ages. The LEPR SNPs rs1137100 (K109R) and rs1137101 (Q223R), and LEP SNP rs7799039 (G2548A) were also associated to hs-CRP levels (p<0.05) in both cohorts. CONCLUSIONS: hs-CRP levels in healthy Spanish children, besides being associated to common polymorphisms in the CRP gene, are associated to polymorphisms in the LEP and LEPR genes, which suggests that other loci, in addition the CRP gene, may have a role determining CRP levels in children.