Incorporating PHI in decision making: external validation of the Rotterdam risk calculators for detection of prostate cancer.

PURPOSE: External validation of existing risk calculators (RC) to assess the individualized risk of detecting prostate cancer (PCa) in prostate biopsies is needed to determine their clinical usefulness. The objective was to externally validate the Rotterdam Prostate Cancer RCs 3 and 4 (RPCRC-3/4) and that incorporating PHI (RPCRC-PHI) in a contemporary Spanish cohort. METHODS: Multicenter prospective study that included patients suspicious of harboring PCa. Men who attended the urology consultation were tested for PHI before prostate biopsy. To evaluate the performance of the prediction models: discrimination (receiver operating characteristic (ROC) curves), calibration and net benefit [decision curve analysis (DCA)] were calculated. These analyses were carried out for detection of any PCa and clinically significant (cs)PCa, defined as ISUP grade ≥ 2. RESULTS: Among the 559 men included, 337 (60.28%) and 194 (34.7%) were diagnosed of PCa and csPCa, respectively. RPCRC-PHI had the best discrimination ability for detection of PCa and csPCa with AUCs of 0.85 (95%CI 0.82-0.88) and 0.82 (95%CI 0.78-0.85), respectively. Calibration plots showed that RPCRC-3/4 underestimates the risk of detecting PCa showing the need for recalibration. In DCA, RPCRC-PHI shows the highest net benefit compared to biopsy all men. CONCLUSIONS: The RPCRC-PHI performed properly in a contemporary clinical setting, especially for prediction of csPCa.

Do PHI and PHI density improve detection of clinically significant prostate cancer only in the PSA gray zone?

OBJECTIVES: Prostate health index (PHI) is a predictive biomarker of positive prostate biopsy. The majority of evidence refers to its use in the PSA gray zone (4-10 ng/mL) and negative digital rectal exam (DRE). We aim to evaluate and compare the predictive accuracy of PHI and PHI density (PHId) with PSA, percentage of free PSA and PSA density, in a wider range of patients for the detection of clinically significant prostate cancer (csPCa). METHODS: Multicenter prospective study that included patients suspicious of harboring prostate cancer. Non-probabilistic convenience sampling, where men who attended the urology consultation were tested for PHI before prostate biopsy. To evaluate and compare diagnostic accuracy AUC and decision curve analysis (DCA) were calculated. All these procedures were performed for the overall sample and the following subsamples: PSA < 4 ng/ml; PSA 4-10 ng/ml; PSA 4-10 ng/ml plus negative DRE and PSA > 10 ng/ml. RESULTS: Among the 559 men included, 194 (34.7%) were diagnosed of csPCa. PHI and PHId outperfomed PSA in all subgroups. PHI best diagnostic performance was found in PSA 4-10 ng/ml with negative DRE (sensitivity 93.33, NPV 96.04). Regarding AUC, significant differences were found between PHId and PSA in the subgroup of PSA 4-10 ng/ml, whatever DRE status. In DCA, PHI density shows the highest net benefit. CONCLUSIONS: PHI and PHId outperfom PSA in csPCa detection, not only in the PSA grey zone with negative DRE, but also in a wider range of PSA values. There is an urgent need of prospective studies to established a validated threshold and its incorporation in risk calculators.

Factors Associated With Peripheral Nerve Injury After Pelvic Laparoscopy: The Importance of Surgical Positioning.

BACKGROUND: Nerve damage after abdominal and pelvic surgery is rare but potentially serious. The incidence of peripheral nerve injury is difficult to assess, and rates of between 0.02% and 21% have been cited in the literature. Signs and symptoms of this type of injury may appear immediately after surgery or a few days later. PURPOSE: This study was developed to assess the rate of peripheral nerve injury after pelvic laparoscopy and to identify associated risk factors. METHODS: A pilot prospective cohort study was conducted between March 2018 and April 2019 on 101 patients with a 1-month follow-up using two semistructured clinical interviews. We carried out a descriptive analysis followed by univariable and multivariable logistic regression analyses. RESULTS: Thirteen patients were found to have peripheral nerve injuries, representing a rate of 12.9%. Overall, 14 injuries (five severe and nine mild) were detected. One patient had two mild injuries. In this study, the risk of injury was found to increase 1.77-fold (OR = 1.77, 95% CI [1.13, 2.76], p = .007) for each hour the patient was in the Trendelenburg position. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: The longer the patient is in the Trendelenburg position, the greater the risk of peripheral nerve damage. Patients aged 60 years or less also face a higher risk of nerve injury.

Influence of Diagnostic Delay on Survival Rates for Patients with Colorectal Cancer.

Colorectal cancer affects men and women alike. Sometimes, due to clinical-pathological factors, the absence of symptoms or the failure to conduct screening tests, its diagnosis may be delayed. However, it has not been conclusively shown that such a delay, especially when attributable to the health system, affects survival. The aim of the present study is to evaluate the overall survival rate of patients with a delayed diagnosis of colorectal cancer. This observational, prospective, multicenter study was conducted at 22 public hospitals located in nine Spanish provinces. For this analysis, 1688 patients with complete information in essential variables were included. The association between diagnostic delay and overall survival at five years, stratified according to tumor location, was estimated by the Kaplan-Meier method. Hazard ratios for this association were estimated using multivariable Cox regression models. The diagnostic delay ≥ 30 days was presented in 944 patients. The presence of a diagnostic delay of more than 30 days was not associated with a worse prognosis, contrary to a delay of less than 30 days (HR: 0.76, 0.64-0.90). In the multivariate analysis, a short delay maintained its predictive value (HR: 0.80, 0.66-0.98) regardless of age, BMI, Charlson index or TNM stage. A diagnostic delay of less than 30 days is an independent factor for short survival in patients with CRC. This association may arise because the clinical management of tumors with severe clinical characteristics and with a poorer prognosis are generally conducted more quickly.

Predictors of in-hospital mortality after ischemic stroke: A prospective, single-center study.

BACKGROUND AND AIMS: Stroke is the second leading cause of death around the globe. Studies examining the predictors of in-hospital mortality and the impact of complications on early outcome of acute ischemic stroke are scant. The aim of this study was to identify predictors of in-hospital mortality in patients with acute ischemic stroke. METHODS: This was a prospective, single-center study of patients with acute ischemic stroke consecutively admitted to the Neurology Department of a general hospital during a 2-year period (from January 1, 2010 to December 31, 2011). Prospective data from this single-center study included variables related to sociodemographics, comorbidities, and medical complications, together with in-hospital mortality. Since stroke mortality may impact differently by sex and is also influenced by hospital length of stay, we proceeded to stratify by these variables. RESULTS: Six-hundred and seventy-three patients were included. Overall, in-hospital mortality rate was 7.13%. Stratifying by length of stay in-hospital (< 7 days and ≥ 7 days), we observed that within the first week, overall mortality was related to a history of previous stroke, higher stroke severity, and to cardiovascular and respiratory complications. After 7 days, the main factor independently associated with overall in-hospital mortality was stroke severity (National Institutes of Health Stroke Scale (NIHSS) ≥ 14, odds ratio (OR): 17.15; 95% CI, 3.06-96.07).Stratifying by sex, we observed that females had a worse outcome if there was a history of prior stroke (OR: 3.29; 95% CI, 1.19-9.10), higher stroke severity (NIHSS ≥ 14, OR: 16.63; 95% CI, 4.66-59.31), and cardiovascular complications (OR: 29.70; 95% CI, 5.70-154.8). Among men, stroke severity (NIHSS ≥ 14, OR: 23.19; 95% CI, 5.69-94.56), respiratory infections (OR: 3.84; 95% CI, 1.32-11.20), and older age had significant negative impact. CONCLUSIONS: Stroke severity and potentially modifiable complications (respiratory infections and cardiovascular complications) confer an increased risk of in-hospital death in both women and men, particularly during the first week of admission.

External validity of a prognostic score for acute heart failure based on the Epidemiology of Acute Heart Failure in Emergency Departments registry: the EAHFE-3D scale. / Validación externa de la escala EAHFE-3D para la evaluación del pronóstico en insuficiencia cardiaca aguda.

OBJECTIVES: To validate the EAHFE-3D scale, based on the Acute Heart Failure in Emergency Departments registry, in a cohort of patients attended for acute heart failure. MATERIAL AND METHODS: Study of a multipurpose cohort of patients with acute heart failure in 3 hospitals in the Basque Country between 2011 and 2013. We extracted age, baseline New York Heart Association functional class, systolic blood pressure, baseline arterial oxygen saturation, sodium level in blood, and emergency department treatments (noninvasive mechanical ventilation, use of inotropic agents and vasopressors) in order to calculate each patient's EAHFE-3D score. The main outcome variable was mortality within 3 days of arrival at the emergency department. RESULTS: The patient sample for score validation consisted of 717 patients with complete information. The model's intercept was 0.5 (95% CI, -2.7 to 3.7) and the slope was 1.3 (95% CI, 0.4 to 2.2). The area under the receiver operating characteristic curve was 0.76 (95% CI, 0.58 to 0.94). CONCLUSION: The EAHFE-3D scale's ability to discriminate was good in this patient sample and similar to that reported by the authors who developed the scale; however, calibration was poor. The scale should be studied further before it is applied in clinical practice.

OBJETIVO: Validar la escala pronóstica EAHFE-3D en una cohorte externa de pacientes atendidos por insuficiencia cardiaca aguda (ICA). METODO: Estudio de cohortes multipropósito que incluyó pacientes con ICA en 3 centros hospitalarios del País Vasco entre 2011 y 2013. Se recogieron los datos demográficos (edad), clase funcional basal (New York Heart Association), clínicos (presión arterial sistólica y saturación de oxígeno basal), analíticos (natremia) y terapéuticos (ventilación mecánica no invasiva e inotrópicos y vasopresores) en el servicio de urgencias (SU) necesarios para el cálculo de la escala EAHFE-3D. La variable de resultado principal fue la mortalidad a tres días de la llegada al SU. RESULTADOS: Analizamos 717 pacientes con información completa. El intercepto ß el modelo fue 0,5 (IC95%: ­2,7- 3,7) y la pendiente α fue de 1,3 (IC95%: 0,4-2,2). El área bajo la curva AUC (ROC) fue 0,76 (IC95%: 0,58-0,94). CONCLUSIONES: La escala EAHFE-3D presentó una buena capacidad predictiva en nuestra muestra, no diferente a la obtenida por los autores originales, aunque no ha mostrado buena calibración. Se recomienda continuar con el proceso de validación antes de ser implementada en la práctica clínica.

Low cognitive reserve is associated with chronic migraine with medication overuse and poor quality of life.

OBJECTIVE: The objective of this article is to test the hypothesis that cognitive reserve (CR) is related to migraine chronification, medication overuse and poor quality of life in migraineurs. DESIGN/METHODS: A cross-sectional study on patients with chronic migraine with medication overuse (CM-MOH), episodic migraine (EM), and controls, matched by sex, age and education, was carried out. CR was assessed by a specific questionnaire, and quality of life was measured by general and specific questionnaires (SF-36 and MSQoL). Migraine Disability Assessment Scale and Beck questionnaires for depression and anxiety were used. Medication dependence was evaluated by the medication-dependence questionnaire in headache (MDQ-H). RESULTS: Fifty-five individuals were enrolled: 18 CM-MOH patients (32.73%), 22 EM patients (40%) and 15 controls (27.27%). Fifty (90.91%) of them were females and aged 43.53 (7.54) years.Univariate analysis showed a significant association between the study group and CR, and all items of the SF-36, anxiety and depression questionnaires, MSQoL and MDQ-H. The lower CR and CM-MOH group were related to a worse quality of life, more anxiety and depression and the highest medication dependence scores.Multivariate analysis showed that higher CR scores were related to higher quality of life as measured by the physical and mental composite scores of the SF-36, and to lower anxiety (beta = -1.08, p = 0.001) and depression (beta = -0.56, p = 0.03) levels. Focusing on MSQoL, the increase in CR was predictive of a better quality of life (beta = 1.88, p < 0.0001). By all the models, the explained variance of the sample ranged from 39% (mental composite score) to 58% (MSQoL). CONCLUSIONS: Low CR appears to be an independent factor associated with the deterioration of quality of life, the presence of anxiety and depression, and drug dependence and medication overuse in CM-MOH.

Right fronto-insular white matter tracts link cognitive reserve and pain in migraine patients.

BACKGROUND: Structural white matter abnormalities in pain-modulating, regions are present in migraine. Whether they are associated with pain chronification and with cognitive reserve is unclear. METHODS: Prospective, cohort, six-month study of adult patients with episodic or chronic migraine, and controls. Cognitive reserve, quality of life, impact of pain on daily living, depression and anxiety were assessed. Participants underwent a diffusion-tensor MRI to establish the integrity of white matter tracts of three regions of interest (ROIs) implicated in pain modulation, emotion, cognition and resilience (anterior insula, anterior cingulate gyrus, and uncinate fasciculus). RESULTS: Fifty-two individuals were enrolled: 19 episodic migraine patients, 18 chronic migraine patients, and 15 controls. The analysis of the fractional anisotropy in the ROIs showed that those patients with the poorest prognosis (i.e., those with chronic migraine despite therapy at six months--long-term chronic migraneurs) had a significantly lower fractional anisotropy in the right ROIs. Participants with higher cognitive reserve also had greater fractional anisotropy in the right anterior insula and both cingulate gyri. Multivariate analysis showed a significant association between cognitive reserve, migraine frequency, and fractional anisotropy in the right-sided regions of interest. CONCLUSIONS: Long-term chronic migraine patients show abnormalities in anterior white matter tracts, particularly of the right hemisphere, involved in pain modulation emotion, cognition and resilience. Robustness in these areas is associated with a higher cognitive reserve, which in turn might result in a lower tendency to migraine chronification.

[Predictive ability of the CT to evaluate cervical lymph nodes in head and neck tumours]. / Capacidad predictiva de la TC para evaluar las adenopatías cervicales en los tumores de cabeza y cuello.

OBJECTIVE: The aim of this study was to determine the predictive value of computed tomography (CT) i.e., its sensitivity and specificity in detecting metastatic lymph nodes of head and neck tumours. We also studied the capacity of CT in correct nodal staging. PATIENTS AND METHODS: A CT was performed on 95 patients diagnosed with neoplastic disease of the pharynx and/or larynx. All patients subsequently underwent cervical lymph node dissections. In the imaging study, the following parameters were considered for suspected radiological nodal involvement: lymph node diameter greater than 10mm, lesion margins poorly defined, capsule enhancement after contrast administration and lymph nodes that, despite their size, had signs of central necrosis. RESULTS: In the dissections, 70.53% resulted N+ in the histological study. The sensitivity of CT was 82.09% and the specificity, 85.71%. The CT detected positivity in 55 of the 67 histologically pathological dissections, while the CT detected negativity in 24 of the 28 dissections histologically negative. The weighted kappa index value was 0.6408, indicating limited capacity for appropriate staging of the lymph nodes. CONCLUSIONS: While the ability of CT to detect metastatic lymph nodes in head and neck tumours is quite acceptable, it is less so for correctly staging them. It is therefore necessary to look for other imaging tests that provide greater accuracy to avoid unnecessary elective neck dissections and to reduce morbidity and mortality from them. We must now pay attention to new imaging techniques such as PET and PET/CT.

[Respiratory day hospital: Impact on the rate of hospital admissions due to chronic obstructive pulmonary disease exacerbations]. / Hospital de día de enfermedades respiratorias: impacto sobre la tasa de ingresos hospitalarios por exacerbaciones de la enfermedad pulmonar obstructiva crónica.

BACKGROUND AND OBJECTIVE: Acute exacerbations of chronic obstructive pulmonary disease (AE-COPD) are considered to be the most important factor in determining the course of the disease, and have great impact on the health care system. We evaluated the effects of a Respiratory Day Hospital (RDH) on the rate of hospital admissions due to AE-COPD. PATIENTS AND METHODS: During 14 months, every case of AE-COPD seen at the RDH and emergency services was recruited prospectively. Patients were excluded when another known cause of exacerbation was present and/or when they required invasive mechanical ventilation. RESULTS: 226 episodes (173 patients) were included (72, SD 8 years old). One hundred and twenty one cases received treatment at the RDH (53.5%). Admissions from the RDH group were noticeably lower (32.2 vs. 66.7%, p<0.001), even in patients with more admissions due to AE-COPD the year before the study. There were no differences either in terms of AE-COPD severity or in readmissions and mortality rates during the follow up. CONCLUSIONS: Management of AE-COPD in a RDH seems to be associated with a lower rate of hospital admissions in comparison with an emergency department.

The predictive value of clinical and epidemiological parameters in the identification of patients with obstructive sleep apnoea (OSA): a clinical prediction algorithm in the evaluation of OSA.

We sought to analyze the predictive value of anthropometric, clinical and epidemiological parameters in the identification of patients with suspected OSA, and their relationship with apnoea/hypopnoea respiratory events during sleep. We studied retrospectively 433 patients with OSA, 361 men (83.37%) and 72 women (16.63%), with an average age of +/-47, standard deviation +/-11.10 years (range 18-75 years). The study variables for all of the patients were age, sex, spirometry, neck circumference, body mass index (BMI), Epworth sleepiness scale, nasal examination, pharyngeal examination, collapsibility of the pharynx (Müller Manoeuvre), and apnoea-hypopnoea index (AHI). Age, neck circumference, BMI, Epworth sleepiness scale, pharyngeal examination and pharyngeal collapse were the significant variables. Of the patients, 78% were correctly classified, with a sensitivity of 74.6% and a specificity of 66.3%. We found a direct relationship between the variables analysed and AHI. Based on these results, we obtained the following algorithm to calculate the prediction of AHI for a new patient: AHI = -12.04 + 0.36 neck circumference +2.2286 pharyngeal collapses (MM) + 0.1761 Epworth + 0.0017 BMI x age + 1.1949 pharyngeal examinations. The ratio variance in the number of respiratory events explained by the model was 33% (r2 = 0.33). The variables given in the algorithm are the best ones for predicting the number of respiratory events during sleep in patients studied for suspected OSA. The algorithm proposed may be a good screening method to the identification of patients with OSA.