Mortality prediction models after radical cystectomy for bladder tumour: A systematic review and critical appraisal.

INTRODUCTION: To identify risk-predictive models for bladder-specific cancer mortality in patients undergoing radical cystectomy and assess their clinical utility and risk of bias. METHODS: Systematic review (CRD42021224626:PROSPERO) in Medline and EMBASE (from their creation until 31/10/2021) was screened to include articles focused on the development and internal validation of a predictive model of specific cancer mortality in patients undergoing radical cystectomy. CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies (CHARMS) and Prediction model Risk Of Bias ASsessment Tool (PROBAST) were applied. RESULTS: Nineteen observational studies were included. The main predictors were sociodemographic variables, such as age (18 studies, 94.7%) and sex (17, 89.5% studies), tumour characteristics (TNM stage (18 studies, 94.7%), histological subtype/grade (15 studies, 78.9%), lymphovascular invasion (10 studies, 52.6%) and treatment with chemotherapy (13 studies, 68.4%). C-index values were presented in 14 studies. The overall risk of bias assessed using PROBAST led to 100% of studies being classified as high risk (the analysis domain was rated to be at high risk of bias in all the studies), and 52.6% showed low applicability. Only 5 studies (26.3%) included an external validation and 2 (10.5%) included a prospective study design. CONCLUSIONS: Using clinical predictors to assess the risk of bladder-specific cancer mortality is a feasibility alternative. However, the studies showed a high risk of bias and their applicability is uncertain. Studies should improve the conducting and reporting, and subsequent external validation studies should be developed.

Lipid Transfer Protein Sensitization: Risk of Anaphylaxis and Molecular Sensitization Profile in Pru p 3-Sensitized Patients.

BACKGROUND: Component-resolved diagnosis reveals the IgE response to many inhaled, food, and other allergens, improving the understanding and diagnosis of allergic diseases. OBJECTIVE: The aims of the study are to study the recognition of different lipid transfer proteins (LTPs) and other allergen families in a large group of people sensitized to Pru p 3 and to analyze the relationship between the clinical entities and the allergens. METHODS: This cross-sectional study included a large cohort of patients with positive skin tests to peach fruit and Pru p 3 specific IgE antibodies. Respiratory and food allergy symptoms were collected, and we performed prick tests with pollen, plant food, and other allergens plus the ImmunoCAP ISAC assay. RESULTS: Our sample consisted of 421 people with a mean age of 33.25 years (range 16-68); 54.6% were women. Clinical entities included anaphylaxis (37.1%), urticaria (67.9%), and oral allergy syndrome (59.1%). Rhinitis, rhinoconjunctivitis, and/or asthma were diagnosed in 71.8% of the participants. The most pronounced correlation existed between sensitization to Pru p 3 and to Jug r 3, Pla a 3, Ara h 9, and Cor a 8. We found a higher incidence of anaphylaxis in people with 5 or more recognized LTPs. No association was observed between inhaled and food allergies. CONCLUSION: Most Pru p 3-sensitized participants were sensitized to additional allergens from the same family and, to a lesser extent, to other allergens, mainly in the profilin and PR-10 protein families. Anaphylaxis occurred in more than a third of the cases evaluated, and almost three-quarters of them had respiratory symptoms. Respiratory and food allergies involving LTPs do not seem to be associated.

Effect of rowing on mobility, functionality, and quality of life in women with and without breast cancer: a 4-month intervention.

PURPOSE: Of the different modalities of rowing, dragon boat training is the most analyzed in breast cancer (BC). However, other types of boats, such as the felucca, use different biomechanical techniques, which have not been studied in the scientific literature. Consequently, in this study, we sought to determine the benefits of felucca rowing on the physical, psychological, and emotional well-being of patients with BC and healthy persons. METHODS: A pre- and post-intervention, single-arm study without a control group with a 4-month intervention was carried out in Spain in 2019. The study sample included six women with BC and 15 healthy women. The following questionnaires were administered before and after the intervention: Disabilities of the Arm, Shoulder, and Hand (DASH), Constant-Murley score (CMS), and the European Quality of Life 5 Dimensions (EQ-5D, rate your health today). Differences were determined before and after the intervention using the paired t test. RESULTS: Significant differences (p < 0.05) were found in the results of all the questionnaires for the women with BC and for the healthy women: DASH (- 13.8 BC and - 6.7 healthy), CMS (+ 12.0 BC and 9.2 healthy), and EQ-5D (+ 8.5 BC and 10.5 healthy). CONCLUSION: Felucca rowing showed benefits in health and quality of life in both women with BC and healthy women. In future studies with controlled design, values regarding clinical relevance, such as effect sizes/confidence intervals, are needed to corroborate our results.

A critical appraisal of the prognostic predictive models for patients with sepsis: Which model can be applied in clinical practice?

BACKGROUND: Sepsis is associated with high mortality and predictive models can help in clinical decision-making. The objective of this study was to carry out a systematic review of these models. METHODS: In 2019, we conducted a systematic review in MEDLINE and EMBASE (CDR42018111121:PROSPERO) of articles that developed predictive models for mortality in septic patients (inclusion criteria). We followed the CHARMS recommendations (Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies), extracting the information from its 11 domains (Source of data, Participants, etc). We determined the risk of bias and applicability (participants, outcome, predictors and analysis) through PROBAST (Prediction model Risk Of Bias ASsessment Tool). RESULTS: A total of 14 studies were included. In the CHARMS extraction, the models found showed great variability in its 11 domains. Regarding the PROBAST checklist, only one article had an unclear risk of bias as it did not indicate how missing data were handled while the others all had a high risk of bias. This was mainly due to the statistical analysis (inadequate sample size, handling of continuous predictors, missing data and selection of predictors), since 13 studies had a high risk of bias. Applicability was satisfactory in six articles. Most of the models integrate predictors from routine clinical practice. Discrimination and calibration were assessed for almost all the models, with the area under the ROC curve ranging from 0.59 to 0.955 and no lack of calibration. Only three models were externally validated and their maximum discrimination values in the derivation were from 0.712 and 0.84. One of them (Osborn) had undergone multiple validation studies. DISCUSSION: Despite most of the studies showing a high risk of bias, we very cautiously recommend applying the Osborn model, as this has been externally validated various times.

The Victorian Institute of Sport Assessment Scale for Patellar Tendinopathy (VISA-P): A Reliability Generalization Meta-analysis.

OBJECTIVE: The Victorian Institute of Sport Assessment-Patella (VISA-P) is a questionnaire to assess the severity of patellar tendinopathies. Its use requires good reliability indicators: internal consistency, test-retest and parallel forms. Several studies have been published examining this question, but to date the reliability of this questionnaire (meta-analysis) has not been generalized. The aim of this study was to perform a meta-analysis to generalize the reliability of the VISA-P. DATA SOURCES: MEDLINE, EMBASE, and Scopus. STUDY SELECTION: Studies included were those examining the reliability coefficients of the VISA-P: Cronbach alpha, intraclass correlation coefficient (ICC), and parallel-forms (correlation coefficients compared with other scales). DATA EXTRACTION: All coefficients were extracted and the mean reliability was obtained using fixed- or random-effects models. Sensitivity (leave-one-out analysis) was analyzed. Quality assessment was performed using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. DATA SYNTHESIS: Of 364 scientific articles, 12 fulfilled meta-analysis criteria. The summary statistic was 0.86 [95% confidence interval (CI): 0.78-0.92] for Cronbach alpha and 0.94 (95% CI: 0.89-0.97) for the ICC. Parallel forms depended on the comparative test used, ranging from -0.83 to 0.68. The sensitivity analysis found an influential study for the parallel-forms reliability in the Blazina score. We were unable to analyze the asymmetry of funnel plots and meta-regression models because of the number of studies. CONCLUSIONS: The reliability of VISA-P for assessing the severity of patellar tendinopathies requires greater evaluation with more scientific evidence before it can be implemented in clinical practice.

A general presentation on how to carry out a CHARMS analysis for prognostic multivariate models.

The CHARMS (critical appraisal and data extraction for systematic reviews of prediction modelling studies) checklist was created to provide methodological appraisals of predictive models, based on the best available scientific evidence and through systematic reviews. Our purpose is to give a general presentation on how to carry out a CHARMS analysis for prognostic multivariate models, making clear what the steps are and how they are applied individually to the studies included in the systematic review. This tutorial is aimed at providing such a resource. In addition to this explanation, we will apply the method to a real case: predictive models of atrial fibrillation in the community. This methodology could be applied to other predictive models using the steps provided in our review so as to have complete information for each included model and determine whether it can be implemented in daily clinical practice.

Clusters of Cardiovascular Risk Factors and Their Impact on the 20-Year Cardiovascular Risk in a General Population.

BACKGROUND: Clustering of cardiovascular risk factors (CVRFs) is extraordinarily common and is associated with an increased risk of cardiovascular disease (CVD). However, the particular impact of the sum of CVRFs on cardiovascular morbidity and mortality has not been sufficiently explored in Europe. OBJECTIVE: The aim of this study was to analyze the differences in survival-free probability of CVD in relation to the number of CVRFs in a Spanish population. METHODS: A prospective cohort study was conducted from 1992 to 2016 in a Spanish population that included 1144 subjects with no history of CVD (mean age, 46.7 years) drawn from the general population. We calculated the number of CVRFs for each subject (male sex, smoking, diabetes, hypertension, dyslipidemia, obesity, and left ventricular hypertrophy). Cardiovascular morbidity and mortality records were collected, and survival analysis was applied (competing risk models). RESULTS: There were 196 cardiovascular events (17.1%). The differences in total survival-free probability of cardiovascular morbidity and mortality of the different values of the sum of CVRFs were significant, increasing the risk of CVD (hazard ratio, 1.30; 95% confidence interval, 1.13-1.50) per each additional risk factor. CONCLUSION: Differences in survival-free probability of CVD in relation to the number of CVRFs present were statistically significant. Further studies are needed to corroborate our results.

A systematic review of predictive models for recurrence and mortality in patients with tongue cancer.

INTRODUCTION: Predictive models must meet clinical/methodological standards to be used in clinical practice. However, no critique of those models relating to mortality/recurrence in tongue cancer has been done bearing in mind the accepted standards. METHODS: We conducted a systematic review evaluating the methodology and clinical applicability of predictive models for mortality/recurrence in tongue cancer published in MEDLINE and Scopus. For each model, we analysed (domains of CHARMS, Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies) the following: source of data, participants, outcome to be predicted, candidate predictors, sample size, missing data, model development, model performance, model evaluation, results and interpretation and discussion. RESULTS: We found two papers that included eight prediction models, neither of which adhered to the CHARMS recommendations. CONCLUSION: Given the quality of tongue cancer models, new studies following current consensus are needed to develop predictive tools applicable in clinical practice.

Clinical inertia in hypertension: a new holistic and practical concept within the cardiovascular continuum and clinical care process.

Purpose: Recognition of clinical inertia is essential to improve the control of chronic diseases. Although it is very intuitive, a better interpretation of the concept of clinical inertia is lacking, likely due to its high complexity. Materials and Methods: After a review of the published articles, we propose a practical vision of inertia, contextualized within the clinical process of hypertension care. Results: This new vision enables the integration of previous terms and definitions of clinical inertia, as well as proposing specific strategies for its reduction. Conclusion: Although some concepts should be considered as 'justified inertia' or 'investigator inertia', the idea that inertia may be present throughout the continuum of care gives physicians a holistic view of the problem that is easily applicable to their clinical practice. Measures to overcome inertia are complicated because of the intrinsic complexity of the concept.

A scoring system to predict recurrence in patients with differentiated thyroid cancer.

OBJECTIVES: Though predictive models have been constructed to determine the risk of recurrence in differentiated thyroid carcinoma, various aspects of these models are inadequate. Therefore, we aimed to construct, internally validate and implement on a mobile application a scoring system to determine this risk within 10 years. DESIGN: A retrospective cohort study in 1984-2016. SETTING: A Spanish region. PARTICIPANTS: We enrolled 200 patients with differentiated thyroid carcinoma without distant metastasis at diagnosis. MAIN OUTCOME MEASURES: Time-to-recurrence. A risk table was constructed based on the sum of points to estimate the likelihood of recurrence. The model was internally validated and implemented as a mobile application for Android. RESULTS: Predictive factors were follicular histology, T, N and multifocality. This risk table had a C-statistic of 0.723. The calibration was satisfactory. CONCLUSIONS: This study provides an instrument able to predict rapidly and very simply which patients with differentiated thyroid carcinoma have a greater risk of recurrence.

A scoring system to predict 5-year mortality in patients diagnosed with laryngeal glottic cancer.

Only one prognostic model for laryngeal cancer has been published, but it has not been properly validated and is only applicable to patients treated with radiotherapy. Consequently, we constructed, internally validated and implemented in an App (Android), a predictive model of 5-year mortality in patients with glottic cancer in a cohort study of 189 patients with glottic cancer in 2004-2016 in Spain. The main variable was time-to-death. Secondary variables were age, gender, TNM, stage, smoking, alcohol consumption, histology and treatment. A scoring system to predict mortality at 5 years was constructed, validated internally by bootstrapping and then integrated into an Android app. In all, 70 patients died (37.0%, 76 deaths per 1,000 patient-years). The predictive model had the following prognostic factors: larger tumour size, greater degree of lymph node metastasis, higher stage, smoking and alcohol consumption. The internal validation of the model through bootstrapping was satisfactory. In conclusion, a points system to predict mortality at 5 years in patients with glottic cancer has been constructed, internally validated and integrated into an Android application. External validation is suggested to make available a quick and simple tool to establish the prognosis for these patients.

Screening Tool to Determine Risk of Having Muscle Dysmorphia Symptoms in Men Who Engage in Weight Training at a Gym.

OBJECTIVE: Although 2 screening tests exist for having a high risk of muscle dysmorphia (MD) symptoms, they both require a long time to apply. Accordingly, we proposed the construction, validation, and implementation of such a test in a mobile application using easy-to-measure factors associated with MD. DESIGN: Cross-sectional observational study. SETTING: Gyms in Alicante (Spain) during 2013 to 2014. PARTICIPANTS: One hundred forty-one men who engaged in weight training. ASSESSMENT OF RISK FACTORS: The variables are as follows: age, educational level, income, buys own food, physical activity per week, daily meals, importance of nutrition, special nutrition, guilt about dietary nonadherence, supplements, and body mass index (BMI). A points system was constructed through a binary logistic regression model to predict a high risk of MD symptoms by testing all possible combinations of secondary variables (5035). The system was validated using bootstrapping and implemented in a mobile application. MAIN OUTCOME MEASURES: High risk of having MD symptoms (Muscle Appearance Satisfaction Scale). RESULTS: Of the 141 participants, 45 had a high risk of MD symptoms [31.9%, 95% confidence interval (CI), 24.2%-39.6%]. The logistic regression model combination providing the largest area under the receiver operating characteristic curve (0.76) included the following: age [odds ratio (OR) = 0.90; 95% CI, 0.84-0.97, P = 0.007], guilt about dietary nonadherence (OR = 2.46; 95% CI, 1.06-5.73, P = 0.037), energy supplements (OR = 3.60; 95% CI, 1.54-8.44, P = 0.003), and BMI (OR = 1.33, 95% CI, 1.12-1.57, P < 0.001). The points system was validated through 1000 bootstrap samples. CONCLUSIONS: A quick, easy-to-use, 4-factor test that could serve as a screening tool for a high risk of MD symptoms has been constructed, validated, and implemented in a mobile application.

Comparison Between Non-High-Density Lipoprotein Cholesterol and Low-Density Lipoprotein Cholesterol to Estimate Cardiovascular Risk Using a Multivariate Model.

BACKGROUND: Although studies exist comparing low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol (HDL-C) in the development of cardiovascular disease (CVD), most have limitations in the mathematical models used to evaluate their prognostic power adjusted for the other risk factors (cardiovascular risk). OBJECTIVE: The aim of this study was to compare LDL-C and non-HDL-C in patients with CVD to determine whether both parameters predict CVD similarly. METHODS: A cohort of 1322 subjects drawn from the general population of a Spanish region was followed between 1992 and 2006. The outcome was time to CVD. Secondary variables were gender, age, hypertension, diabetes, personal history of CVD, current smoker, body mass index, LDL-C, and non-HDL-C. Two CVD prediction models were constructed with the secondary variables, with only the lipid parameter varying (non-HDL-C or LDL-C). In the construction of the models, the following were considered: multiple imputation, events per variable of 10 or more, and continuous predictors as powers. The validation was conducted by bootstrapping obtaining the distribution of the C statistic (discrimination) and the probabilities observed by smooth curves. These results were compared in both models using graphical and analytical testing. RESULTS: There were a total of 137 CVD events. The models showed no differences in the distributions of the C statistic (discrimination, P = .536) or in the calibration plot. CONCLUSIONS: In our population, LDL-C and non-HDL-C were equivalent at predicting CVD. More studies using this methodology are needed to confirm these results.

Burnout syndrome in nurses working in palliative care units: An analysis of associated factors.

AIMS: To analyse the association between psychological, labour and demographic factors and burnout in palliative care nursing. BACKGROUND: There is a lack of published research evaluating burnout in palliative care nursing. METHODS: This observational cross-sectional study involved 185 palliative care nurses in Mexico. The primary variables were burnout defined by its three dimensions (emotional exhaustion, depersonalization and personal accomplishment). As secondary variables, psychological, labour and demographic factors were considered. A binary logistic regression model was constructed to determine factors associated with burnout. RESULTS: A total of 69 nurses experienced high emotional exhaustion (37.3%), 65 had high depersonalization (35.1%) and 70 had low personal performance (37.8%). A higher proportion of burnout was found in the participants who were single parents, working >8 hr per day, with a medium/high workload, a lack of a high professional quality of life and a self-care deficit. CONCLUSION: Our multivariate models were very accurate in explaining burnout in palliative care nurses. These models must be externally validated to predict burnout and prevent future complications of the syndrome accurately. IMPLICATIONS FOR NURSING MANAGEMENT: Nurses who present the factors found should be the focus of interventions to reduce work stress.

Relationship between the rs1414334 C/G polymorphism in the HTR2C gene and smoking in patients treated with atypical antipsychotics. / Relación entre el polimorfismo rs1414334 C/G del gen HTR2C y tabaquismo en pacientes tratados con antipsicóticos atípicos.

An association has been found between the C allele of the rs1414334 polymorphism in the HTR2C gene and the metabolic syndrome in psychiatric patients. However, no study has yet evaluated whether this allele is associated with smoking. To assess this issue, therefore, we performed a cross-sectional study with a sample of 166 adult patients treated with atypical antipsychotics in 2012-2013 in a region of Spain. The primary variable was the presence of the C allele of the rs1414334 polymorphism in the HTR2C gene. Secondary variables were the number of pack-years (number of cigarettes per day x number of smoking years ÷ 20), age, gender, schizophrenia, years since diagnosis, metabolic syndrome criteria and SCORE. A stepwise binary logistic regression model was constructed to determine associations between primary and secondary variables and their area under the ROC curve (AUC) was calculated. Of the total sample, 33 patients (19.9%) had the C allele of the polymorphism analyzed. Mean cigarette consumption was 11.6 pack-years. The multivariate analysis showed the following factors as associated with the polymorphism: higher cigarette consumption, being a woman, and not having abdominal obesity. The AUC was 0.706. An association was found between increased cigarette consumption over the years and the presence of the C allele of the rs1414334 polymorphism in the HTR2C gene.

En pacientes psiquiátricos, otros autores han encontrado una asociación entre el alelo C del polimorfismo rs1414334 del gen HTR2C y el síndrome metabólico. Ninguno de ellos ha valorado si este alelo se asocia con el consumo de tabaco, por lo que se decidió realizar un estudio en una región española valorando esta cuestión. Estudio observacional transversal de una muestra de 166 pacientes adultos tratados con antipsicóticos atípicos en 2012-2013. Variable principal: presencia del alelo C del polimorfismo rs1414334 del gen HTR2C. Variables secundarias: número de años-paquete (número de cigarrillos al día x número de años fumando ÷ 20), edad, sexo, esquizofrenia, años diagnosticados del trastorno, criterios de síndrome metabólico y SCORE. Se construyó un modelo de regresión logística binaria por pasos para determinar asociaciones entre la variable principal y las variables secundarias del estudio y se calculó su área bajo la curva ROC (ABC). Del total de la muestra, 33 pacientes presentaron el alelo C del polimorfismo analizado (19,9%). El consumo de tabaco medio fue de 11.6 paquetes-año. El modelo multivariante arrojó los siguientes factores asociados al polimorfismo: mayor consumo tabáquico, ser mujer y no tener obesidad abdominal. El ABC fue de 0,706. Se ha encontrado asociación entre un mayor consumo de tabaco a lo largo de los años y la presencia del alelo C del polimorfismo rs1414334 del gen HTR2C. Se necesitan trabajos que corroboren nuestros resultados.

Nonadherence to guidelines for prescribing antiplatelet/anticoagulant therapy in patients with atrial fibrillation.

BACKGROUND: We have found no papers evaluating nonadherence to guidelines for the treatment of atrial fibrillation (AF), taking into account the two risk scales [C, congestive heart failure; H, hypertension; A, age; D, diabetes mellitus; S, stroke (CHADS2) and C, congestive heart failure; H, hypertension; A, age; D, diabetes mellitus; S, stroke; V, vascular disease; A, age; Sc, sex category (CHA2DS2-VASc)] and the two types of treatment that are recommended (antiplatelet/anticoagulant therapy). OBJECTIVE: To determine the extent of lack of adherence when prescribing anticoagulant and antiplatelet therapy to patients with AF and associated factors. METHODS: Cross-sectional, observational study of 144 patients with AF who visited the emergency department of Elda Hospital in 2013-14 (Spain). Main variable: the patient was prescribed a therapy different from that indicated by the guidelines (nonadherence) or not prescribed any therapy. Secondary variables: CHADS2, CHA2DS2-VASc, HAS-BLED, type of AF and symptoms related to AF. Multivariate models were constructed to identify the associated factors by calculating the adjusted odds ratios (OR). RESULTS: Nonadherence occurred in 90 patients [62.5%, 95% confidence interval (CI): 54.6-70.4%]. Associated factors were higher CHADS2 (OR = 1.30, 95% CI: 0.96-1.75, P = 0.091) and CHA2DS2-VASc (OR = 1.23, 95% CI: 1.02-1.47, P = 0.027), and lower HAS-BLED (OR = 0.67, 95% CI: 0.49-0.91, P = 0.011). CONCLUSIONS: Nonadherence to guidelines was found in three out of every five patients. A greater cerebrovascular risk and a lower haemorrhagic risk were associated with this behaviour. Qualitative studies are needed to determine the causes.

Construction and internal validation of a new mortality risk score for patients admitted to the intensive care unit.

BACKGROUND: The existing models to predict mortality in intensive care units (ICU) present difficulties in clinical practice. OBJECTIVES: The aim of this study was to develop and internally validate a points system to predict mortality in the ICU, which can be applied instantly and with high discriminating power. METHODS: This cohort study comprised all patients admitted to the ICU in a Spanish region between January 2013 and April 2014, followed from admission to death or discharge (N=1113). Primary variable: ICU mortality. Secondary variables at admission: gender, Fried criteria for frailty, function scale, medical admission, cardiac arrest, cardiology admission, sepsis, mechanical ventilation, inotropic support, age, frailty index and clinical frailty scale. The sample was divided randomly into two groups (80% and 20%): construction (n=844) and internal validation (n=269). Construction: A logistic regression model was implemented and adapted to the points system. VALIDATION: the area under the ROC curve (AUC) of the model was calculated and the risk quintiles were created to determine whether differences existed between observed and expected deaths. RESULTS: The points system included: function scale, medical admission, cardiology admission, sepsis, mechanical ventilation and inotropic support. The validation showed: (i) AUC=0.95 (95% CI: 0.91-0.99, p<.001); (ii) No differences between observed and expected deaths (p=.799). CONCLUSIONS: A predictive model of mortality in the ICU has been constructed and internally validated. This model improves on the previous models through its simplicity, its discriminating power and free use. External validation studies are needed in other geographical areas.

Effectiveness Analysis of Active Stretching Versus Active Stretching Plus Low-Frequency Electrical Stimulation in Children Who Play Soccer and Who Have the Short Hamstring Syndrome.

OBJECTIVE: To determine the effectiveness of active stretching (AS) versus AS plus electrical stimulation (stretching + TENS) in young soccer players with the short hamstring syndrome (SHS). DESIGN: Randomized, controlled, single-blind parallel clinical trial with 3 arms and a 2-month follow-up. The assignment ratio was 1:1:1. SETTING: The study involved young federated soccer players in the town of Jumilla, in the region of Murcia (Spain), who were controlled in a physiotherapy office in 2012. PARTICIPANTS: Fifty-one young soccer players (10-16 years) with SHS. INTERVENTIONS: Stretching + TENS, AS, and conventional stretching. MAIN OUTCOME MEASURES: Straight leg raise (SLR) test, popliteal angle with the passive knee extension (PKE) test, and the toe-touch test (TT). RESULTS: Significant results (P < 0.05) were group 1 versus 2: (1) SLR, -5.5 degrees right; (2) PKE, +10.2 degrees right and +6.2 degrees left; and (3) range of values of clinically relevant parameters (RVCRP): relative risk (RR), 0.35 to 0.38; relative risk reduction (RRR), 0.62 to 0.65; absolute risk reduction (ARR), 0.32 to 0.39; number needed to treat (NNT), 3 to 4. Group 1 versus 3: (1) SLR, -12.3 degrees right and -10 degrees left; (2) PKE, +12.9 degrees right and +8.5 degrees left; (3) TT, -8.9 cm; and (4) RVCRP: RR, 0.12 to 0.28; RRR, 0.72 to 0.88; ARR, 0.60 to 0.83; NNT, 2 to 2. Group 2 versus 3: (1) SLR, -6.8 degrees right and -6.2 degrees left; (2) TT, -6.7 cm; (3) RVCRP: RR, 0.44 to 0.53; RRR, 0.47 to 0.56; ARR, 0.40 to 0.56; NNT, 2 to 3. CONCLUSIONS: Stretching + TENS produces greater improvement than AS alone, and these are both better than conventional stretching. CLINICAL RELEVANCE: The use of electrical stimulation combined with AS is a relevant technique for habitual clinical practice that should be systematically integrated in children aged 10 to 16 years who play soccer and who have the SHS.

Food Protein-Induced Enterocolitis Syndrome in Adulthood: Clinical Characteristics, Prognosis, and Risk Factors.

BACKGROUND: Food protein-induced enterocolitis syndrome (FPIES) in adults is being increasingly recognized; however, little is known about its characteristics. OBJECTIVE: To describe the clinical characteristics, prognosis, and associated factors in adult FPIES. METHODS: A 10-year prospective study was conducted in the Allergy Section of Alicante General Hospital in adults diagnosed with FPIES. Detailed interviews with patients and oral food challenges (OFCs) were performed to confirm diagnosis or evaluate for tolerance. Comorbidities and possible risk factors were analyzed retrospectively through electronic medical records to assess their association with the disease. RESULTS: One hundred and seven adults with FPIES (93.5% female) were followed for a median of 6.2 years. Abdominal pain was the most common manifestation (96.3%), followed by diarrhea (72%) and vomiting (60.7%). Seafood (59.8%), egg (14%), and milk (10.3%) were the most common triggers, whereas 43.9% reacted to more than 1 food group. We performed 49 OFCs: 9 to confirm diagnosis and 40 to evaluate for tolerance. After a median 3.5 years, 16.8% achieved tolerance. Resolution was correlated inversely with duration of the disease (P = .04) and seafood (P = .023) but not with age of onset. The prevalence of gastrointestinal pathologies such as irritable bowel syndrome (IBS), eosinophilic esophagitis, inflammatory bowel disease, and celiac disease was higher than in the general population. A higher number of FPIES triggers were correlated with also having a diagnosis of IBS (P = .02). CONCLUSIONS: Although adult FPIES normally persists, some patients achieve tolerance. Adults with FPIES have a relatively high prevalence of gastrointestinal pathologies. The predominance of women may be related to hormonal factors. The clinical differences with pediatric FPIES warrant a revision of diagnostic criteria in adults.

Impact of a clinical pathway on cardiovascular risk in patients with diabetes.

OBJECTIVES: Clinical pathways (CPs) are interventions that target the way clinical practice guidelines are applied. They can be implemented in different diseases, including diabetes. In this study we evaluated the impact of the implementation of a CP in the control of cardiovascular risk factors and the occurrence of new events in patients with type 2 diabetes. METHODS: A pre- and post-intervention population-based study in a Spanish region, conducted in 2014-2016. Variables before and after the intervention were: screening; good control of diabetes, dyslipidemia and hypertension; hypoglycemia and hyperglycemic decompensation; obesity; cardiovascular events; diabetic ketoacidosis; hyperglycemic and hypoglycemic coma. Proportional differences and parameters of clinical relevance (absolute and relative risk reduction, relative risk and number needed to treat) were calculated. RESULTS: The CP achieved an improvement in all outcomes, reducing events and increasing control of different cardiovascular parameters. The greatest improvement was in metabolic control (HbA1c) (37.1% in younger patients and 34.0% in older patients) and screening (5.4%). Indicators of clinical relevance showed that the CP was able to improve metabolic control of diabetes with little effort and great benefit. CONCLUSION: The CP was of considerable benefit to metabolic control as well as control of dyslipidemia and obesity. Screening for diabetes also benefitted. The CP decreased the incidence of events, especially of angina pectoris.