Standards for the Use of Enteral Nutrition in Patients with Diabetes or Stress Hyperglycaemia: Expert Consensus.

(1) Background: Hyperglycaemia that occurs during enteral nutrition (EN) should be prevented and treated appropriately since it can have important consequences for morbidity and mortality. However, there are few quality studies in the literature regarding the management of EN in this situation. The objective of this project was to attempt to respond, through a panel of experts, to those clinical problems regarding EN in patients with diabetes or stress hyperglycaemia (hereinafter referred to only as hyperglycaemia) for which we do not have conclusive scientific evidence; (2) Methods: The RAND/UCLA Appropriateness Method, a modified Delphi panel method, was applied. A panel of experts made up of 10 clinical nutrition specialists was formed, and they scored on the appropriateness of EN in hyperglycaemia, doing so in two rounds. A total of 2992 clinical scenarios were examined, which were stratified into five chapters: type of formula used, method of administration, infusion site, treatment of diabetes, and gastrointestinal complications. (3) Results: consensus was detected in 36.4% of the clinical scenarios presented, of which 23.7% were deemed appropriate scenarios, while 12.7% were deemed inappropriate. The remaining 63.6% of the scenarios were classified as uncertain; (4) Conclusions: The recommendations extracted will be useful for improving the clinical management of these patients. However, there are still many uncertain scenarios reflecting that the criteria for the management of EN in hyperglycaemia are not completely standardised. More studies are required to provide quality recommendations in this area.

The impact of disease changes and mental health illness on readapted return to work after repeated sick leaves among Brazilian public university employees.

Introduction: Health affects work absenteeism and productivity of workers, making it a relevant marker of an individual's professional development. Objectives: The aims of this article were to investigate whether changes in the main cause of the sick leaves and the presence of mental health illnesses are associated with return to work with readaptation. Materials and methods: A historical cohort study was carried out with non-work-related illnesses suffered by statutory workers of university campuses in a medium-sized city in the state of São Paulo, Brazil. Two exposures were measured: (a) changes, throughout medical examinations, in the International Classification of Diseases (ICD-10) chapter regarding the main condition for the sick leave; and (b) having at least one episode of sick leave due to mental illness, with or without change in the ICD-10 chapter over the follow-up period. The outcome was defined as return to work with adapted conditions. The causal model was established a priori and tested using a multiple logistic regression (MLR) model considering the effects of several confounding factors, and then compared with the same estimators obtained using Targeted Machine Learning. Results: Among workers in adapted conditions, 64% were health professionals, 34% had had changes in the ICD-10 chapter throughout the series of sick leaves, and 62% had diagnoses of mental health issues. In addition, they worked for less time at the university and were absent for longer periods. Having had a change in the illness condition reduced the chance of returning to work in another function by more than 30%, whereas having had at least one absence because of a cause related to mental and behavioral disorders more than doubled the chance of not returning to work in the same activity as before. Conclusion: These results were independent of the analysis technique used, which allows concluding that there were no advantages in the use of targeted maximum likelihood estimation (TMLE), given its difficulties in access, use, and assumptions.

Human Immunodeficiency Virus (HIV) Infection Is Associated With Lower Risk of Hepatocellular Carcinoma After Sustained Virological Response to Direct-acting Antivirals in Hepatitis C Infected Patients With Advanced Fibrosis.

BACKGROUND: The aim of this study was to assess the impact of human immunodeficiency virus (HIV) infection on the risk of developing hepatocellular carcinoma (HCC) in patients infected with hepatitis C virus (HCV) who achieve sustained virological response (SVR) with direct-acting antiviral (DAA). METHODS: Multisite prospective cohort study, where HCV-monoinfected patients and HIV/HCV-coinfected individuals were included if they met: (1) SVR with DAA-based combination; (2) liver stiffness (LS) ≥9.5 kPa previous to treatment; (3) LS measurement at the SVR time-point. The main endpoint was the occurrence of HCC. Propensity score (PS) was calculated to address potential confounders due to unbalanced distribution of baseline characteristics of HIV/HCV-coinfected and HCV-monoinfected patients. RESULTS: In total, 1035 HCV-infected patients were included, 667 (64%) coinfected with HIV. After a median (Q1-Q3) follow-up time of 43 (31-49) months, 19 (1.8%) patients developed HCC (11 [3.0%]; HCV-monoinfected, 8[1.2%]; HIV/HCV-coinfected individuals; P = .013). In the multivariable analysis, HIV coinfection was associated with a lower adjusted risk of developing HCC (subhazard ratio [sHR] = 0.27, 95% confidence interval [CI]: .08-.90; P = .034). Predictors of HCC emergence were: HCV genotype 3 (sHR = 7.9, 95% CI: 2.5-24.9; P < .001), MELD score at SVR >10 (sHR = 1.37, 95% CI: 1.01-1.86; P = .043) and LS value at SVR (sHR = 1.03, 95% CI: 1.01-1.06, for 1 kPa increase; P = .011). Using inverse probability weighting method on the PS, HIV-infected patients had a lower risk of HCC (powered HR = 0.33, 95% CI: .11-.85). CONCLUSIONS: Among HCV-infected patients with advanced fibrosis, who achieve SVR with DAA, HIV coinfection seems to be associated with a lower risk of HCC occurrence. The underlying causes for this finding need to be investigated.

Seasonal Variations in Macrophages/Microglia Underlie Changes in the Mouse Model of Multiple Sclerosis Severity.

Both immune and neurodegenerative mechanisms underlie multiple sclerosis (MS) and its animal model, experimental autoimmune encephalomyelitis (EAE). MS/EAE are triggered by encephalitogenic immune cells, including Th1 and Th17 cells, whereas T regulatory (Treg) cells are involved in inflammation resolution. Pro-inflammatory macrophages/microglia also play a deleterious role in the disease. Seasonal variations in MS relapses, active lesions, and pro- and anti-inflammatory cytokine levels have been described in MS patients and have been related with both perinatal and adult exposure to sunlight and other environmental factors. However, some data in EAE mice suggest that these variations might be, at least partially, endogenously determined. Thus, our objective was to study the effect of the season of birth and disease induction on the course of EAE, and immune cell infiltration in the central nervous system (CNS) in myelin oligodendrocyte glycoprotein (MOG35-55)-induced EAE in 8 weeks old, female C57BL/6N mice maintained under constant, controlled conditions. EAE severity as well as pathogenic (Th1, Th17, macrophages/microglia) and protective (Treg) subsets was found to vary according to the season of birth or of EAE induction. Summer-born or summer-immunized animals developed a milder disease, which coincided with variations in numbers of T effector/regulatory subsets, and significantly low numbers of macrophages/microglia. These results suggest that endogenous rhythms in immune responses might cause seasonal variations in EAE severity, and, maybe, in the course of MS, and that they might be related to macrophages/microglia.

[Validation of the "Palliative Care Difficulties Scale (PCDS)" questionnaire in the spanish population about health professionals´ difficulties in palliative care]. / Validación del cuestionario "Palliative Care Difficulties Scale (PCDS)" en población española, sobre dificultades de profesionales sanitarios en cuidados paliativos.

OBJECTIVE: Knowing the difficulties in the application of palliative care would allow us to propose improvement strategies. The objective was to determine the metric properties of the Palliative Care Difficulties Scale (PCDS) translated and adapted to Spanish. METHODS: An instrumental validation study was designed in a regional hospital and primary care centers of a health district. 148 health professionals participated. Sociodemographic and professional variables were collected by a questionnaire about palliative care training and experience, as well as items from the PCDS. The statistical analysis was done with the SPSS 19.0 program. RESULTS: It was verified the comprehension of the translation and back translation of the questionnaire, in a pilot study with 30 professionals. Subsequently, in the survey of 118 professionals, an endorsement frequency of not more than 51% was found for content validity. As for the construct validity, the calculation of the sample adequacy, using the Kaiser-Meyer-Olkin index obtained a value of 0.76. The principal component factor analysis reached a total variance of 73.88% with all items. The correlation of factors ranged from 0.2 to 0.3; so the Varimax rotation was established. The correlation between the items of each factor was higher than 0.6. For the reliability analysis, the internal consistency obtained a Cronbach alpha value of 0.87. In the test-retest reliability analysis, Spearman's Rho correlation for the scale was 0.81. CONCLUSIONS: It was obtained an instrument translated and culturally adapted to Spanish, with adequate validity and reliability to measure difficulties in palliative care.

OBJETIVO: Conocer las dificultades en la aplicación de cuidados paliativos, permitiría proponer estrategias de mejora. El objetivo del estudio fue validar la traducción de la "Escala de Dificultades en Cuidados Paliativos (PCDS)", traducida y adaptada al español. METODOS: Se realizó un estudio de validación instrumental, en un hospital comarcal y centros de atención primaria de un distrito sanitario. Participaron 148 profesionales sanitarios. Mediante una encuesta, recogimos variables sociodemográficas y profesionales sobre la formación y experiencia en cuidados paliativos, así como los ítems del cuestionario PCDS. El análisis estadístico se hizo con el programa SPSS 19.0. RESULTADOS: Comprobamos la comprensión de la traducción y retrotraducción del cuestionario en un estudio piloto con 30 profesionales. Posteriormente, encuestamos a 118 profesionales, encontrando una frecuencia de endose no superior al 51% para la validez de contenido. En cuanto a la validez de constructo, el cálculo de la adecuación muestral, mediante el índice de Kaiser-Meyer- Olkin obtuvo un valor de 0,76. En el análisis factorial por componentes principales encontramos una varianza total explicada del 73,88% con todos los ítems. La correlación de factores osciló entre 0,2 y 0,3, así que se estableció la rotación Varimax. La correlación entre los ítems de cada factor fue superior a 0,6. Para el análisis de fiabilidad, la consistencia interna obtuvo un valor alfa de Cronbach de 0,87. En el análisis de fiabilidad test-retest, la correlación Rho de Spearman para la escala fue de 0,81. CONCLUSIONES: Disponemos de un instrumento traducido y adaptado culturalmente al español, con validez y fiabilidad adecuadas para la medición de dificultades en cuidados paliativos.

Validación del cuestionario "Palliative Care Difficulties Scale (PCDS)" en población española, sobre dificultades de profesionales sanitarios en cuidados paliativos / Validation of the "Palliative Care Difficulties Scale (PCDS)" questionnaire in the spanish population about health professionals' difficulties in palliative care

OBJETIVO: Conocer las dificultades en la aplicación de cuidados paliativos, permitiría proponer estrategias de mejora. El objetivo del estudio fue validar la traducción de la "Escala de Dificultades en Cuidados Paliativos (PCDS)", traducida y adaptada al español. MÉTODOS: Se realizó un estudio de validación instrumental, en un hospital comarcal y centros de atención primaria de un distrito sanitario. Participaron 148 profesionales sanitarios. Mediante una encuesta, recogimos variables sociodemográficas y profesionales sobre la formación y experiencia en cuidados paliativos, así como los ítems del cuestionario PCDS. El análisis estadístico se hizo con el programa SPSS 19.0. RESULTADOS: Comprobamos la comprensión de la traducción y retrotraducción del cuestionario en un estudio piloto con 30 profesionales. Posteriormente, encuestamos a 118 profesionales, encontrando una frecuencia de endose no superior al 51% para la validez de contenido. En cuanto a la validez de constructo, el cálculo de la adecuación muestral, mediante el índice de Kaiser-Meyer- Olkin obtuvo un valor de 0,76. En el análisis factorial por componentes principales encontramos una varianza total explicada del 73,88% con todos los ítems. La correlación de factores osciló entre 0,2 y 0,3, así que se estableció la rotación Varimax. La correlación entre los ítems de cada factor fue superior a 0,6. Para el análisis de fiabilidad, la consistencia interna obtuvo un valor alfa de Cronbach de 0,87. En el análisis de fiabilidad test-retest, la correlación Rho de Spearman para la escala fue de 0,81. CONCLUSIONES: Disponemos de un instrumento traducido y adaptado culturalmente al español, con validez y fiabilidad adecuadas para la medición de dificultades en cuidados paliativos

OBJECTIVE: Knowing the difficulties in the application of palliative care would allow us to propose improvement strategies. The objective was to determine the metric properties of the Palliative Care Difficulties Scale (PCDS) translated and adapted to Spanish. METHODS: An instrumental validation study was designed in a regional hospital and primary care centers of a health district. 148 health professionals participated. Sociodemographic and professional variables were collected by a questionnaire about palliative care training and experience, as well as items from the PCDS. The statistical analysis was done with the SPSS 19.0 program. RESULTS: It was verified the comprehension of the translation and back translation of the questionnaire, in a pilot study with 30 professionals. Subsequently, in the survey of 118 professionals, an endorsement frequency of not more than 51% was found for content validity. As for the construct validity, the calculation of the sample adequacy, using the Kaiser-Meyer-Olkin index obtained a value of 0.76. The principal component factor analysis reached a total variance of 73.88% with all items. The correlation of factors ranged from 0.2 to 0.3; so the Varimax rotation was established. The correlation between the items of each factor was higher than 0.6. For the reliability analysis, the internal consistency obtained a Cronbach alpha value of 0.87. In the test-retest reliability analysis, Spearman's Rho correlation for the scale was 0.81. CONCLUSIONS: It was obtained an instrument translated and culturally adapted to Spanish, with adequate validity and reliability to measure difficulties in palliative care

Factores determinantes en la indicación de la prótesis invertida de hombro / Facteurs déterminant l'indication de prothèse d'épaule inversée / Determining Factors in Inverted Shoulder Prosthesis Indication

Objetivo: Desarrollar criterios para determinar las indicaciones apropiadas de la prótesis invertida de hombro en artropatías por lesión del manguito rotador y las variables determinantes de este proceso. Método: Se utilizó un panel de expertos mediante metodología RAND/UCLA con 9 expertos en Traumatología, 2 en Rehabilitación y 1 en Reumatología, que evaluaron 192 casos hipotéticos. Cada experto puntuó mediante una escala del 1 (extremadamente inadecuado) al 9 (extremadamente apropiado). Resultados: 22 casos hipotéticos fueron considerados adecuados. El dolor, limitación funcional, necesidad funcional, defecto glenoideo, edad, artrosis y posibilidad de reparación del manguito rotador son variables determinantes para indicar la implantación de una prótesis invertida de hombro. Conclusiones: El método RAND/UCLA es útil para el estudio de las indicaciones de procedimientos como la prótesis invertida de hombro, y proporciona una lista de las indicaciones adecuadas. Las variables requieren ser validadas mediante estudios prospectivos o revisión de historias clínicas(AU)

Objective: Develop criteria to determine the appropriate indications of inverted shoulder prosthesis in arthropathies due to rotator cuff injury and the variables that determine this process. Method: A panel of experts assessed 192 hypothetical cases using RAND/UCLA methodology. Nine Traumatology experts, two Rehabilitation experts and one Rheumatology expert comprised this panel. Each expert scored on a scale from 1 (extremely unsuitable) to 9 (extremely appropriate). Results: 22 hypothetical cases were considered adequate. Pain, functional limitation, functional need, glenoid defect, age, osteoarthritis and possibility of rotator cuff repair are determining as variables to indicate the implantation of an inverted shoulder prosthesis. Conclusions: The RAND/UCLA method is useful for the study of procedure indications such as the inverted shoulder prosthesis, and it provides a list of suitable indications. Prospective studies or medical record reviews should validate these variables(AU)

Objectif: Proposer les critères définissant l'indication appropriée de prothèse d'épaule inversée dans les arthropathies pour lésion de la coiffe des rotateurs, et les variables déterminant ce processus. Méthodes: Un panel d'experts, compris par 9 traumatologues, 2 kinésithérapeutes et 1 rhumatologue, a été utilisé pour évaluer 192 cas hypothétiques par la méthode RAND/UCLA. Chaque expert a fait son évaluation sur une échelle de 1 (extrêmement inapproprié) à 9 (extrêmement approprié). Résultats: Vingt-deux cas hypothétiques ont été considérés comme appropriés. Des variables telles que la douleur, la limitation fonctionnelle, la nécessité fonctionnelle, le défaut glénoïdien, l'âge, l'arthrose et la possibilité de correction de la coiffe des rotateurs, ont déterminé l'indication de prothèse d'épaule inversée. Conclusions: La méthode RAND-UCLA est utile pour l'étude des indications de procédés, tels que la prothèse d'épaule inversée, et procure une liste des indications appropriées. Il faut valider les variables avec des études prospectives ou une révision des dossiers médicaux(AU)

Tratamiento quirúrgico de lesiones melanocíticas benignas para la prevención del melanoma. Revisión sistemática / Management of benign melanocytic lesions as a melanoma prevention. Systematic review

Debido a una creciente sensibilidad sobre el cáncer de piel, posiblemente se está realizando un número excesivo de intervenciones quirúrgicas de lesiones melanocíticas como medida profiláctica. Se realizó una revisión sistemática de la literatura médica de estudios primarios sobre la efectividad y coste-efectividad de la cirugía de lesiones melanocíticas benignas como prevención del melanoma. Se incluyeron 19 estudios primarios sobre tratamiento quirúrgico de lesiones melanocíticas adquiridas y una evaluación económica. Las medidas de efectividad, como el número necesario a tratar y la ratio de malignidad, dependen de factores como la especialidad y experiencia del médico, la presión por parte del paciente o las características de este. La detección precoz del melanoma es fundamental. Sin embargo, existen factores que aumentan la proporción de lesiones tratadas innecesariamente. Se necesita una cuidadosa aplicación de técnicas de identificación de lesiones sospechosas y programas educativos dirigidos a los médicos, especialmente de atención primaria (AU)

There is a growing concern and awareness of skin cancer. As a result, possibly unnecessary surgeries of melanocytic lesions are carried out as a prophylactic measure. We performed a systematic review of the medical literature to identify primary studies on the effectiveness and cost-effectiveness of surgery treatment of benign melanocytic lesions for melanoma prevention. We included 19 primary studies on surgical treatment of acquired melanocytic lesions and one economic evaluation. Indicators, such as number needed to treat and the malignancy ratio, depend on several factors such as specialty and experience of the physician, pressure from the patient or patient characteristics. Early diagnosis of melanoma is critical in preventing skin cancer. However, primary studies show through several indicators that there are factors that increase the proportion of lesions treated unnecessarily. Effectiveness can be improved by careful use of techniques to identify suspicious lesions and educational programs for physicians, especially in primary care (AU)

Tres nuevas estrategias para mejorar la precisión de la estimulación vestibular calórica monotérmica / Three new strategies to improve the accuracy of monothermal caloric screening testing

Objetivo: Encontrar una forma de estimar el valor de paresia canalicular (PC) a través de la estimulación vestibular calórica monotérmica (EVCM) que pueda utilizarse en cualquier laboratorio, controlando el error que se produce al utilizarla. Método: Se incluyó en este estudio a 2.304 pacientes de nuestro servicio a los cuales se les realizó una videonistagmografía con pruebas calóricas entre 2003 y 2011. El cálculo de la PC se realizó de 3 formas diferentes: utilizando los valores de las 4 estimulaciones calóricas (forma bitérmica) o exclusivamente con los 2 valores de una misma temperatura (formas monotérmica caliente y fría respectivamente). Se estudiaron 3 estrategias para mejorar la precisión de la EVCM: análisis de variables que empeoran la predicción, delimitación de un área gris de predicción deficiente y localización de un punto de separación entre sanos y enfermos de máxima utilidad. Resultados: 1) Corregir la fórmula de Jongkees con el valor del nistagmo espontáneo permite incluir como candidatos a la EVCM a sujetos con nistagmo espontáneo o inversión nistágmica. 2) Establecer una zona gris de predicción deficiente evita aproximadamente el 38% de las estimulaciones bitérmicas realizadas, con una sensibilidad y especificidad del 95%. 3) La máxima utilidad de la EVCM se obtiene al considerar como función vestibular normal la de sujetos con valores de EVCM caliente menores o iguales al 16%, suponiendo patológica una asimetría mayor del 20%. Conclusión: Las nuevas herramientas estadísticas permiten a los clínicos tomar decisiones que afecten al manejo de sus pacientes basados en los resultados de la EVCM (AU)

Objective: The objective was to find a way to estimate the value of inter-ear difference (IED) through monothermal caloric screening testing (MCST) that can be used at any laboratory, controlling and minimising the resulting error. Methods: We retrospectively included in this study 2304 patients from our department to whom a videonystagmography with caloric testing was performed between 2003 and 2011. The IED was calculated in 3 different ways: Using the values of the 4 caloric stimulations (bithermal form) and using only the 2 same-temperature values (warm monothermal and cool monothermal forms). We studied 3 strategies to improve the accuracy of MCST: Analysis of variables that could impair the prediction, delimitation of a grey area of insufficient prediction and location of a maximum utility cut-off point. Results: Correcting Jongkees’ formula with the value for spontaneous nystagmus makes it possible to include subjects with spontaneous nystagmus or nystagmus inversion. Establishing 2 cut-off points to classify the subjects avoids approximately 38% of bithermal stimulations performed with a sensitivity and specificity of 95%. Maximum utility was obtained diagnosing as healthy those subjects with IED values lesser than or equal to 16% in warm MCST when the pathological IED was set as greater than 20%. Conclusion: New statistical tools help clinicians to make decisions that affect their patients based on the results of MCST (AU)

[Management of benign melanocytic lesions as a melanoma prevention. Systematic review]. / Tratamiento quirúrgico de lesiones melanocíticas benignas para la prevención del melanoma. Revisión sistemática.

There is a growing concern and awareness of skin cancer. As a result, possibly unnecessary surgeries of melanocytic lesions are carried out as a prophylactic measure. We performed a systematic review of the medical literature to identify primary studies on the effectiveness and cost-effectiveness of surgery treatment of benign melanocytic lesions for melanoma prevention. We included 19 primary studies on surgical treatment of acquired melanocytic lesions and one economic evaluation. Indicators, such as number needed to treat and the malignancy ratio, depend on several factors such as specialty and experience of the physician, pressure from the patient or patient characteristics. Early diagnosis of melanoma is critical in preventing skin cancer. However, primary studies show through several indicators that there are factors that increase the proportion of lesions treated unnecessarily. Effectiveness can be improved by careful use of techniques to identify suspicious lesions and educational programs for physicians, especially in primary care.

Three new strategies to improve the accuracy of monothermal caloric screening testing.

OBJECTIVE: The objective was to find a way to estimate the value of inter-ear difference (IED) through monothermal caloric screening testing (MCST) that can be used at any laboratory, controlling and minimising the resulting error. METHODS: We retrospectively included in this study 2304 patients from our department to whom a videonystagmography with caloric testing was performed between 2003 and 2011. The IED was calculated in 3 different ways: Using the values of the 4 caloric stimulations (bithermal form) and using only the 2 same-temperature values (warm monothermal and cool monothermal forms). We studied 3 strategies to improve the accuracy of MCST: Analysis of variables that could impair the prediction, delimitation of a grey area of insufficient prediction and location of a maximum utility cut-off point. RESULTS: Correcting Jongkees' formula with the value for spontaneous nystagmus makes it possible to include subjects with spontaneous nystagmus or nystagmus inversion. Establishing 2 cut-off points to classify the subjects avoids approximately 38% of bithermal stimulations performed with a sensitivity and specificity of 95%. Maximum utility was obtained diagnosing as healthy those subjects with IED values lesser than or equal to 16% in warm MCST when the pathological IED was set as greater than 20%. CONCLUSION: New statistical tools help clinicians to make decisions that affect their patients based on the results of MCST.

Análisis del tratamiento quirúrgico más apropiado para la colecistitis aguda mediante aplicación del método RAND/UCLA / Analysis of the most appropriate surgical treatment for acute cholecystitis by applying the RAND/UCLA method

Introducción: La colecistitis aguda (CA) constituye una indicación frecuente de colecistectomía. Las circunstancias locales y ciertas características de los pacientes provocan unas altas tasas de fracaso y complicaciones de la colecistectomía laparoscópica (CL) y, a pesar de la experiencia ganada, aún no disponemos de una lista de indicaciones pormenorizada que permita minimizarlas. Material y método Empleamos el análisis de la adecuación RAM para evaluar 2 opciones, la CL y la colecistectomía abierta (OC). Un panel de expertos analizó su idoneidad tras una revisión de la bibliografía, una reunión de consenso y 2 rondas de puntuaciones sobre diferentes situaciones clínicas. Se analizó la puntuación sobre cada escenario para establecer el grado de adecuación de cada opción. Resultados Tras la reunión presencial quedaron definidos 64 escenarios, lográndose un acuerdo en las indicaciones en el 67,18% de ellos. En el 86,04% de los escenarios el acuerdo fue por adecuación de las indicaciones. Cuando la colecistectomía estuvo indicada siempre lo fue por laparoscopia, mientras que solo en ocasiones lo fue por laparotomía. En pacientes con menos de 72 h de evolución se consideró apropiada siempre la CL cuando se presentasen con sepsis, o bien sin ella pero con datos ecográficos de CA complicada. Conclusiones Sigue existiendo incertidumbre respecto al manejo de la CA, en especial respecto al momento de la intervención y la vía de abordaje, particularmente en pacientes frágiles y con evoluciones de la clínica superiores a las 72 h. El método RAND puede ayudar a tomar decisiones sobre la adecuación de distintas opciones terapéuticas (AU)

Introduction: Acute cholecystitis (AC) is a common indication for cholecystectomy. Local circumstances and certain patient characteristics lead to high failure rates and complications in laparoscopic cholecystectomy (LC), and despite the experience gained, we still do not have a detailed list of indications which could minimise them. Material and method: We used the RAND/UCLA Appropriateness Method (RAM) to evaluate2 options, LC and open cholecystectomy (OC). An expert panel analysed its suitability after a literature review, a consensus meeting, and 2 rounds of scores on different clinical situations. The score of each scenario was analysed to establish the appropriateness level of each option. Results: At the end of the meeting there were 64 defined scenarios, with an agreement being reached on the indications in 67.18% of them. In 86.04% of the scenarios, the agreement was due to the appropriateness of the indications. When cholecystectomy was indicated, it was always by laparoscopy, while it was only occasionally by laparotomy. In patients with less than 72 h of onset, LC was always considered appropriate when there was sepsis, or even without this if the ultrasound data showed complicated AC. Conclusions: There is still uncertainty as regards the management of AC, especially as regards the timing of the operation and the surgical approach, particularly in frail patients and with a clinical onset greater than 72 h. The RAND method can help to make decisions on the appropriateness of different therapeutic options (AU)

[Analysis of the most appropriate surgical treatment for acute cholecystitis by applying the RAND/UCLA method]. / Análisis del tratamiento quirúrgico más apropiado para la colecistitis aguda mediante aplicación del método RAND/UCLA.

INTRODUCTION: Acute cholecystitis (AC) is a common indication for cholecystectomy. Local circumstances and certain patient characteristics lead to high failure rates and complications in laparoscopic cholecystectomy (LC), and despite the experience gained, we still do not have a detailed list of indications which could minimise them. MATERIAL AND METHOD: We used the RAND/UCLA Appropriateness Method (RAM) to evaluate 2 options, LC and open cholecystectomy (OC). An expert panel analysed its suitability after a literature review, a consensus meeting, and 2 rounds of scores on different clinical situations. The score of each scenario was analysed to establish the appropriateness level of each option. RESULTS: At the end of the meeting there were 64 defined scenarios, with an agreement being reached on the indications in 67.18% of them. In 86.04% of the scenarios, the agreement was due to the appropriateness of the indications. When cholecystectomy was indicated, it was always by laparoscopy, while it was only occasionally by laparotomy. In patients with less than 72 h of onset, LC was always considered appropriate when there was sepsis, or even without this if the ultrasound data showed complicated AC. CONCLUSIONS: There is still uncertainty as regards the management of AC, especially as regards the timing of the operation and the surgical approach, particularly in frail patients and with a clinical onset greater than 72 h. The RAND method can help to make decisions on the appropriateness of different therapeutic options.

Appropriate management of common bile duct stones: a RAND Corporation/UCLA Appropriateness Method statistical analysis.

BACKGROUND: Bile duct stones affect 10% of patients who undergo a cholecystectomy and therefore represent a major health problem. Laparoscopic common bile duct exploration, endoscopic sphincterotomy, and open surgical choledocholithotomy are the three available methods for dealing with choledocholithiasis. Though many trials and reviews have compared all three strategies, a list of indications for defined patient profiles is lacking. METHODS: We employed the RAND Corporation/UCLA Appropriateness Method (RAM) to evaluate the three procedures for bile duct stone clearance. An expert panel judged appropriateness after a comprehensive bibliography review, a first-round private rating of 108 different clinical situations, a consensus meeting, and a second round of definitive rating. A list of indications for each procedure was statistically calculated. RESULTS: A consensus was reached for 41 indications (38%). The endoscopic approach was always appropriate for preoperatively diagnosed bile duct stones and inappropriate for patients with single intraoperative detected stones causing cholangitis and bile duct dilatation. Laparoscopic bile duct exploration was appropriate for preoperatively diagnosed choledocholithiasis if patients had not undergone a previous cholecystectomy and no signs of cholangitis were detected. The laparoscopic approach was also appropriate for intraoperatively incidentally detected stones, except for septic patients with poor performance status and multiple calculi. Laparoscopic bile duct clearance was judged inappropriate for septic patients with poor performance status and absence of bile duct dilatation. Open surgery was appropriate in all patients with intraoperative diagnosis of choledocholithiasis and cholangitis and in septic patients with bile duct dilatation. There was no clinical situation in which open surgery was appropriate when bile duct stones were preoperatively diagnosed. CONCLUSIONS: There is still uncertainty with respect to the management of choledocholithiasis, showing the need for further investigation. The RAM helps to elucidate appropriateness for the different treatment options in specific clinical settings.

Assessing the appropriate use of laparoscopic surgery for hepatobiliary diseases.

BACKGROUND: The range of indications for laparoscopic surgery has widened since it was first introduced. The aim of the present study was to develop standards for the appropriate use of laparoscopic surgery in patients with choledocholithiasis or cholelithiasis. METHOD: We conducted a study following the RAND appropriateness method (RAM) to develop criteria for hepatobiliary laparoscopy. A panel comprised of 7 experts rated the appropriateness of a set of indications, from 1 (very inappropriate) to 9 (very appropriate). The panelists performed ratings in 2 rounds. The first round was performed independently by every expert. The second round took place during a face-to-face meeting. According to the median of panelists' ratings and agreement criteria, every indication was classified as appropriate, uncertain, or inappropriate. RESULTS: In the first round, 112 (46.7%) indications were judged as appropriate, 102 (42.5%) as uncertain, and 26 (10.8%) as inappropriate. In the second round, 99 indications (48.5%) were considered as appropriate, 81 (39.7%) as uncertain, and 24 (11.8%) as inappropriate. Disagreement between panelists decreased in the second round compared with the first round. Thirteen indications were rated as disagreement (6.4%), 125 as uncertain (61.3%), and 66 as agreement (32.3%), while in the first round, the results and proportions were 44 (18.3%), 132 (55.0%), and 64 (26.7%), respectively. CONCLUSIONS: By using RAM, the panel was able to develop detailed explicit appropriateness criteria for the proper application of hepatobiliary laparoscopy. The criteria may be used prospectively to help in making clinical decisions or retrospectively to assess the overuse of clinical procedures.

Salud oral de los escolares de Ceuta. Influencias de la edad, el género, la etnia y el nivel socioeconómico / Oral health of schoolchildren in Ceuta. Influences of age, sex, ethnic background and socioeconomic level

Fundamento: La caries dental tiene una etiología multifactorial en la que intervienen características del huésped (saliva y esmalte dental), de la flora bucal (placa bacteriana) y del substrato sobre el que ésta se desarrolla (higiene oral y dieta). El objetivo de este trabajo es medir la prevalencia de caries, enfermedad periodontal y maloclusión en la población escolar de Ceuta, y su distribución según edad, género, etnia y nivel socioeconómico (NSE) -medido a través de la ocupación paterna-.Métodos: Se realizó una exploración física de la cavidad bucal a una muestra de escolares de 7, 12 y 14 años (n=347) del distrito sanitario de Ceuta con el fin de calcular los índices cao -dentición temporal-, CAO -dentición definitiva-, CPITN y de maloclusión. La selección de la muestra se realizó de forma aleatoria, estratificada polietápica. Se valoró la significación estadística de las diferencias encontradas aplicando las pruebas de Chi-cuadrado, T de Student. y F de Snedecor. Se calcularon las razones de ventaja (Odds Ratio), según sexo, etnia y NSE, de un índice CAO superior a la mediana de la distribución en escolares de 12 y 14 años.Resultados: El índice cao (piezas cariadas, ausentes y obturadas en dentición temporal) es 3,02 a los 7 años y el índice CAO (piezas cariadas, ausentes y obturadas en dentición definitiva) es 3,91 a los 12 años y 4,46 a los 14 años. Las razones de ventaja (OR) de un índice CAO> 4 a los 12-14 años y sus intervalos de confianza (IC) son los siguientes: 2,26 según género (IC95 por ciento= 1,27-4,05), 2,17 según etnia (IC95 por ciento=1,18-3,99) y 1,80 según NSE (IC95 por ciento=0,85-3,81). En el estrato de bajo NSE la OR por etnia es 1,38 (IC95 por ciento= 0,28-7,0). No se observan diferencias significativas en la distribución de maloclusión ni de enfermedad periodontal -excepto por edad-.Conclusiones: Los valores del índice CAO en escolares de Ceuta son más elevados que el promedio nacional y superiores al objetivo marcado por la OMS para el año 2000. El riesgo de índice CAO superior a la mediana es en niñas 2,3 veces mayor que en niños, en musulmanes 2,17 veces mayor que en no musulmanes y en escolares con bajo nivel socioeconómico -padres desempleados- 1,8 veces mayor que en escolares con padres activos. El aumento de riesgo asociado a etnia está influenciado por el nivel socioeconómico (AU)

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