Quality Assessment of Clinical Practice Guidelines on the Treatment of Psoriasis Using the AGREE II Tool. / Evaluación de la calidad de guías de práctica clínica para el tratamiento de psoriasis mediante la herramienta AGREE II.

BACKGROUND: Clinical practice guidelines (CPGs) are designed to help health professionals provide patients with excellent medical care. The last critical appraisal of CPGs on the treatment of psoriasis evaluated publications up to 2009, but several new guidelines have been published since and their methodological quality remains unclear. OBJECTIVE: The aim of this study was to systematically evaluate the quality of CPGs on the treatment of psoriasis published between 2010 and 2020 using the Appraisal Guidelines Research and Evaluation II (AGREE II) tool. MATERIAL AND METHODS: We searched for relevant CPGs in MEDLINE, Embase, and LILACS (Latin American and Caribean Health Sciences Literature) as well as in the gray literature. Two reviewers working independently selected the guidelines for analysis and extracted the relevant data. Each guideline was then assessed using the AGREE II instrument by 5 reviewers, also working independently. RESULTS: Nineteen CPGs met the inclusion criteria and most of them had been produced in high-income countries. The mean (SD) domain scores were 84.9% (14.7%) for scope and purpose, 65.5% (19.3%) for stakeholder involvement, 66.7% (15.6%) for rigor of development, 72.8% (16.8%) for clarity of presentation, 46.6% (21.7%) for applicability, and 57.0% (30.4%) for editorial independence. CONCLUSIONS: Although about three-quarters of the CPGs assessed were judged to be of high quality and over half were recommended for use in clinical practice, standards of guideline development need to be raised to improve CPG quality, particularly in terms of applicability and editorial independence, which had the lowest scores in our evaluation.

Fibrosis assessment in patients with nonalcoholic fatty liver disease: Adherence to proposed algorithms and barriers to complying with them.

INTRODUCTION AND AIMS: Fibrosis staging in patients with nonalcoholic fatty liver disease (NAFLD) is carried out through the application of stepwise algorithms but there is little real-world data on their use. Our aim was to calculate the number of patients with NAFLD and indeterminate or high risk for fibrosis, assessed through noninvasive scores, that consequently underwent further staging evaluation. MATERIALS AND METHODS: A cross-sectional multicenter cohort study was conducted on patients with NAFLD evaluated by hepatologists within the time frame of June 1 and July 31, 2018. The FIB-4 and NAFLD fibrosis scores were calculated in all the patients, and if at least one of the scores suggested indeterminate or high risk for fibrosis, we believed the patient should have undergone additional fibrosis staging assessment. RESULTS: The study included 238 patients. The median time interval from NAFLD diagnosis and inclusion in the analysis was 12.2 months (IQR 3.0-36.5). A total of 128 (54%) patients had at least one noninvasive score that suggested indeterminate or high risk for fibrosis but studies to confirm the fibrosis grade (elastography, biopsy, etc.) were performed on only 72 (56%). The main barriers encountered by the physicians for applying the staging algorithms were related to health insurance coverage and imaging study costs. CONCLUSIONS: A high percentage of patients with NAFLD were at indeterminate or high risk for fibrosis, according to noninvasive scores, but additional studies were carried out on only half of them, showing low adherence to current recommendations.

Fibrosis assessment in patients with nonalcoholic fatty liver disease: Adherence to proposed algorithms and barriers to complying with them. / Evaluación de fibrosis en pacientes con enfermedad por hígado graso no alcohólico: adherencia a los algoritmos propuestos y barreras para cumplir con ellos.

INTRODUCTION AND AIMS: Fibrosis staging in patients with nonalcoholic fatty liver disease (NAFLD) is carried out through the application of stepwise algorithms but there is little real-world data on their use. Our aim was to calculate the number of patients with NAFLD and indeterminate or high risk for fibrosis, assessed through noninvasive scores, that consequently underwent further staging evaluation. MATERIALS AND METHODS: A cross-sectional multicenter cohort study was conducted on patients with NAFLD evaluated by hepatologists within the time frame of June 1 and July 31, 2018. The FIB-4 and NAFLD fibrosis scores were calculated in all the patients, and if at least one of the scores suggested indeterminate or high risk for fibrosis, we believed the patient should have undergone additional fibrosis staging assessment. RESULTS: The study included 238 patients. The median time interval from NAFLD diagnosis and inclusion in the analysis was 12.2months (IQR 3.0-36.5). A total of 128 (54%) patients had at least one noninvasive score that suggested indeterminate or high risk for fibrosis but studies to confirm the fibrosis grade (elastography, biopsy, etc.) were performed on only 72 (56%). The main barriers encountered by the physicians for applying the staging algorithms were related to health insurance coverage and imaging study costs. CONCLUSIONS: A high percentage of patients with NAFLD were at indeterminate or high risk for fibrosis, according to noninvasive scores, but additional studies were carried out on only half of them, showing low adherence to current recommendations.

Methodology Proposal of EMG Hand Movement Classification Based on Cross Recurrence Plots.

Dealing with electromyography (EMG) signals is often not simple. The nature of these signals is nonstationary, noisy, and high dimensional. These EMG characteristics make their predictability even more challenging. Cross recurrence plots (CRPs) have demonstrated in many works their capability of detecting very subtle patterns in signals often buried in a noisy environment. In this contribution, fifty subjects performed ten different hand movements with each hand with the aid of electrodes placed in each arm. Furthermore, the nonlinear features of each subject's signals using cross recurrence quantification analysis (CRQA) have been performed. Also, a novel methodology is proposed using CRQA as the mainstream technique to detect and classify each of the movements presented in this study. Additional tools were presented to determine to which extent this proposed methodology is able to avoid false classifications, thus demonstrating that this methodology is feasible to classify surface EMG (SEMG) signals with good accuracy, sensitivity, and specificity. Lastly, the results were compared with traditional machine learning methods, and the advantages of using the proposed methodology above such methods are highlighted.

Exploring the QSAR's predictive truthfulness of the novel N-tuple discrete derivative indices on benchmark datasets.

Graph derivative indices (GDIs) have recently been defined over N-atoms (N = 2, 3 and 4) simultaneously, which are based on the concept of derivatives in discrete mathematics (finite difference), metaphorical to the derivative concept in classical mathematical analysis. These molecular descriptors (MDs) codify topo-chemical and topo-structural information based on the concept of the derivative of a molecular graph with respect to a given event (S) over duplex, triplex and quadruplex relations of atoms (vertices). These GDIs have been successfully applied in the description of physicochemical properties like reactivity, solubility and chemical shift, among others, and in several comparative quantitative structure activity/property relationship (QSAR/QSPR) studies. Although satisfactory results have been obtained in previous modelling studies with the aforementioned indices, it is necessary to develop new, more rigorous analysis to assess the true predictive performance of the novel structure codification. So, in the present paper, an assessment and statistical validation of the performance of these novel approaches in QSAR studies are executed, as well as a comparison with those of other QSAR procedures reported in the literature. To achieve the main aim of this research, QSARs were developed on eight chemical datasets widely used as benchmarks in the evaluation/validation of several QSAR methods and/or many different MDs (fundamentally 3D MDs). Three to seven variable QSAR models were built for each chemical dataset, according to the original dissection into training/test sets. The models were developed by using multiple linear regression (MLR) coupled with a genetic algorithm as the feature wrapper selection technique in the MobyDigs software. Each family of GDIs (for duplex, triplex and quadruplex) behaves similarly in all modelling, although there were some exceptions. However, when all families were used in combination, the results achieved were quantitatively higher than those reported by other authors in similar experiments. Comparisons with respect to external correlation coefficients (q2ext) revealed that the models based on GDIs possess superior predictive ability in seven of the eight datasets analysed, outperforming methodologies based on similar or more complex techniques and confirming the good predictive power of the obtained models. For the q2ext values, the non-parametric comparison revealed significantly different results to those reported so far, which demonstrated that the models based on DIVATI's indices presented the best global performance and yielded significantly better predictions than the 12 0-3D QSAR procedures used in the comparison. Therefore, GDIs are suitable for structure codification of the molecules and constitute a good alternative to build QSARs for the prediction of physicochemical, biological and environmental endpoints.

Drug resistance trends among previously treated tuberculosis patients in a national registry in Peru, 1994-2001.

SETTING: National mycobacteriology reference laboratory in Peru conducting routine testing of susceptibility to isoniazid, rifampin, ethambutol, pyrazinamide, and streptomycin, in Mycobacterium tuberculosis isolates from previously treated patients. OBJECTIVE: To determine the percentage of isolates resistant to each of five anti-tuberculosis agents and to ascertain in these data the presence of trends of clinical relevance. DESIGN: Retrospective study of a national registry of M. tuberculosis isolates from patients referred for drug susceptibility testing between 1994 and 2001. RESULTS: Among 14,736 isolates tested, 10,837 (73.5%, 95%CI 72.8-74.3) demonstrated anti-tuberculosis resistance, and 8455 (57.4%, 95%CI 56.6-58.2) demonstrated resistance to at least both isoniazid and rifampin, by convention defined as multidrug-resistant tuberculosis (MDR-TB). A significant increasing trend could be discerned for resistance to each of the drugs tested and in isolates classified as MDR-TB (P < 0.001 for trend). Additional clinically relevant trends were found in polyresistance and multidrug resistance percentages. CONCLUSIONS: Data from a national reference laboratory can be used to inform the design of retreatment regimens.

Beliefs about children's illness.

Beliefs about child illness were investigated using semi-structured interviews with mothers and providers in four rural Guatemalan communities. The two most common forms of child illness in Guatemala--diarrhoea and respiratory disease--were focused upon. These illnesses are particularly difficult to prevent and treat, especially with the rudimentary health services available in rural areas of developing countries. Comparisons with other ethnographic studies in Guatemala suggest that some traditional models of illness causation identified in these earlier investigations are relatively unimportant in the communities studied here. This finding, in conjunction with frequent responses related to hygiene and water, suggests that traditional explanations may be co-existing with biomedical views of illness causation to a greater degree today than in the past.

Zinc supplementation affects the activity patterns of rural Guatemalan infants.

Zinc deficiency has been associated with growth deficits, reduced dietary intake and appetite, and has been hypothesized to result in reduced activity. This randomized, double-blind, placebo-controlled study examined whether 10 mg of oral zinc as zinc sulfate, given daily for up to 7 mo, affected activity patterns of 85 Guatemalan infants recruited at 6-9 mo of age. Infant activity was assessed by time sampling-observation method at 10-min intervals during a 12-h data collection period, at base line, 3 and 7 mo follow-up. Motor development and the percentage of time infants were observed in various positions (being carried, lying down, sitting, crawling, standing or walking) and engaged in various activities (eating, sleeping, resting, crying/whining or playing) were compared by treatment group. No differences in motor development were observed by treatment group. However, at follow-up 2 (after 7 mo of supplementation), zinc-supplemented infants were significantly more frequently observed sitting up compared with lying down, and were playing during 4.18 +/- 1.95% (P < 0.05) more observations than unsupplemented infants. They were also somewhat less likely to be observed crying or whining (P < 0.10) compared with those receiving the placebo. These effects are independent of other factors including infant age, motor development, sex, maternal education, family socioeconomic status and nutritional status at base line. Further research must be conducted to determine the long-term developmental importance of these differences in activity patterns associated with zinc supplementation in this setting.

Thoracoendoscopic surgery in the pericardial effusion

Ten cases of pericardial effusion operated on by VATS are presented. Five patients had unspecified effusion, 3 due to breast cancer and 2 by direct invasion of lung cancer. In this series thre were 4 cases of cardiac tamponade and six presented with severe dyspnea. Pericardial effusion was accompanied by pleural effusion in 7 cases. In 3 of them it was the only expression of the disease. In all cases a large pleuropericardial window was performed, in addition to pleural biopsy and electrocautery pleurodesis. There were neither morbidity nor mortality in this series. We conclude that VATS is an excellent method to resolve pericardial effusions without a previous diagnosis, in which medical treatment failed and results of pericardiocentesis were not long lasting.

[Parathyroid scintigraphy with Tc99m Sestamibi]. / Cintigrafía de paratiroides con Tc99m Sestamibi.

BACKGROUND: Parathyroid scintigraphy with Tc99m Sestamibi, a tracer that is taken up by hyperfunctioning parathyroid tissue, has a high yield in the diagnosis of abnormal parathyroid growths. AIM: To assess the usefulness of parathyroid scintigraphy with Tc99m Sestamibi in patients with suspected hyperparathyroidism. PATIENTS AND METHODS: We analyzed retrospectively 29 patients with suspected hyperparathyroidism, in whom a scintigraphy with Tc99m Sestamibi was performed. RESULTS: Twenty four of 25 patients in whom hyperfunctioning parathyroid tissue was evidenced with scintigraphy, were operated. Histological diagnosis of the excised parathyroid gland, showed 23 adenomas and 1 hyperplasia. Anatomical location disclosed by scintigraphy was concordant with surgical findings in all cases, including a mediastinic adenoma. Of the four patients with negative scintigraphic findings, two had transitory PTH elevations and in two the presence of adenoma or hyperplasia could not be demonstrated with other diagnostic procedures. CONCLUSIONS: Parathyroid scintigraphy with Tc99m Sestamibi had an 86% sensitivity for the detection of hyperfunctioning parathyroid tissue in patients with elevated PTH.

Maternal activity budgets: feasibility of exclusive breastfeeding for six months among urban women in Honduras.

Although exclusive breastfeeding for 6 months is likely to be beneficial for infant health, mothers often cite time pressures as a reason to introduce other foods. Using 12-hr in-home observations at 19 and 24 wk postpartum, we compared maternal activity budgets and time spent breastfeeding among low-income, urban mothers not employed outside the home who exclusively breastfed (EBF) or gave other foods in addition to breast milk (BF+SF). Breastfeeding time was similar between groups (averaging approx 75 min/12 hr) except that multiparous EBF mothers at 24 wk spent more time breastfeeding their infants than did BF+SF mothers. However, total time devoted to infant feeding (including preparation and feeding of solids in the BF+SF group) was significantly greater in the BF+SF group than in the EBF group (except among multiparous women at 24 wk). Feeding frequency per 12-hr averaged 6.7-8.9 in the EBF group and 5.4-8.1 BF + 1.8 meals in the BF+SF group. Both EBF and BF+SF mothers had considerable 'free' time; they spent, on average, 2-3 hr during each 12-hr period resting, chatting or watching TV. Primiparous women tended to spend less time at household chores and child care than multiparous women. Of the BF+SF mothers, 60% said that breastfeeding was 'somewhat' or 'very' time-demanding (vs 15% of EBF mothers), 49% said that it interfered with other activities (vs 6% of EBF mothers), and 26% said that they gave other foods to extend the time between breastfeeds. Although many of the BF+SF mothers knew that giving foods may increase infant illness, there were cultural pressures not to exclusively breastfeed. For example, many introduced solids to their infants prior to 6 months because they believed that infants should 'learn' how to eat other foods, to 'acclimate' the stomach and learn to differentiate flavors. We conclude that time constraints are not a barrier to exclusive breastfeeding in this population, although they may be perceived as a barrier.

Association of indicators of hygiene behavior with persistent diarrhea of young children.

We examined the association between water and hygiene-related behaviors and persistent diarrhea (duration > or = 14 days) among children under age three years in an indigenous rural Guatemalan community. Behavior indicators were specific aspects of the appearance of the mother, study child, other children and household that could be observed using a spot observation technique. Thirty-four percent of children had one or more episodes of persistent diarrhea during the year of study. Bivariate analyses found that a higher proportion of observations in which the anti-hygienic condition was observed was significantly associated with persistent diarrhea for 11 of 26 behavior indicators; these 11 indicators were also strongly correlated with each other. In individual logistic regression models, which included overall rate of diarrhea and other child characteristics associated with persistent diarrhea, six behavior indicators maintained significant association with persistent diarrhea: presence of toy on the ground, presence of baby bottle on the ground, the hands of the mother being dirty, presence of a fecally soiled diaper on the ground in the household compound, presence of feces in the yard, and the study child wearing a fecally soiled diaper. Three additional indicators closely approached significant association with persistent diarrhea. Excluding the three soiled diaper indicators, which might be the result rather than the cause of diarrhea, we found the six other behavior indicators to demonstrate a significant dose-response effect in increasing risk of persistent diarrhea. These findings suggest that behaviors which promote increased exposure of young children to enteric pathogens increase risk of persistent diarrhea.

[Physical growth and menarche in Guatemalan adolescents]. / Crecimiento físico y menarquia en adolescentes de Guatemala.

The relationship between anthropometric measurements and age at menarche was studied in a group of Guatemalan adolescents, from urban and rural areas. The data indicate that median age at menarche is significantly higher in Indian adolescents living in rural areas than in non-Indian, the lowest age at menarche being that of adolescents living in urban areas. The age at menarche is positively associated with anthropometric measurements (weight, arm circumference and height) and body composition (body mass index), suggesting that both physical growth and sexual maturation are interacting processes of the same phenomenon known as the development age.

[Platelet labelling with In-111-oxine: platelet survival and the images]. / Marcación de plaquetas con In-111-oxina: sobrevida plaquetaria e imágenes.

We studied 10 male and 2 female normal non-smoker volunteers (mean age 25) by labeling of autologous platelets with 111-In oxine. Daily samples for platelet survival were obtained in all, gamma-camera images in 10 and blood pool digital subtraction with 99m-Tc labeled erythrocytes in 6. Mean platelet count was 594 +/- 235 10(3)/mm3; collagen platelet aggregation pre and post labeling was 74 +/- 4.8 and 70 +/- 10%, respectively. Mean labeling efficacy was 65 +/- 15.4%, mean labeling dose was 201 +/- 79.5 microCi. A linearized initial survival of 7.9 +/- 1 day was obtained. Scintigraphic images showed circulating activity, greater in the spleen, persisting after digital subtraction. The method described can be used for clinical evaluation of platelet disorders and thrombosis.

[Breast feeding in the etiology of diarrhea]. / La lactancia materna en la etiología de la diarrea.

Information derived from different anthropological studies carried out in Guatemala as part of the activities of the maternal and child health and nutrition project reveal that, according to popular beliefs, maternal milk plays a definite role in the etiology of diarrheal diseases in the lactating child. This paper presents information on popular classification of diarrheal diseases that differ from biomedical definitions of same. Different factors that may alter the quality of mothers' breast milk and that may cause gastrointestinal diseases in the lactating child are given in detail. The possibilities and limitations of the popular concept frame of "hot-cold", so common in the popular medical beliefs in Latin American populations, are also pointed out as an explanatory model. Lastly, implications of findings in this study are suggested for public health programs, especially for the communication and education programs on breast feeding, and for the application of the high-risk focus.

PIP: Selected results are presented of studies of diarrhea and its treatment carried out in Guatemala in 1985-1987 and of qualitative studies of child feeding especially during and after diarrhea conducted in 1988-89 by the Nutrition Institute of Central America and Panama (INCAP). This work focuses on ethnoclassification and the role of breast feeding in diarrheal disease, the possibilities and limitations of the common Latin American system of classification into hot or cold properties as an explanatory model for diarrhea, and implications of the findings for public health programs. In the diarrhea studies, 15-20 randomly selected mothers of children under 5 were interviewed in 4 communities of about 1000 inhabitants in both indigenous and Ladino communities. Interviews were also conducted with curanderos, midwives, and other traditional health care providers. The dietary information on children with diarrhea came from focus groups with mothers in 3 marginal urban communities, 3 rural indigenous communities, and 4 rural Ladino communities. Biomedical practice and popular beliefs both consider alterations in the frequency or consistency of stools and stomach pain to be part of the definition of diarrhea. But the mothers viewed diarrhea as either an illness in itself, or 1 symptom of another illness defined by traditional practice such as "empacho" (indigestion) or evil eye, or as a normal accompaniment of changes in child growth and development such as loss of teeth or the 1st steps or words. Diarrhea caused by the mother's mild is believed to be a distinct type that occurs when the milk becomes very cold or hot in the folk classification, or when it is disturbed. Illnesses are viewed as violations of the equilibrium between hot and cold in the diet, activities, emotions, or general state of the nursing mother. Women are considered in a state of cold for about 40 days after birth and should follow specific recommendations for diet, activity, and personal care. Lactation is considered a hot state, and women should continue to consume hot foods to overcome the cold of the postpartum. Lactating women should avoid foods considered very hot, such as coffee, chile, and spicy foods. Strong maternal emotions such as anger or fright are also believed to affect the milk. Treatment may follow various forms depending on the suspected cause, and may include dietary change, consumption of a home or commercial remedy, or complete weaning. Public health programs should take local health systems into account, encouraging favorable prescribed practices such as postpartum rest and attention to the maternal diet. Specific advice to the mother may vary, but health education should maintain the integrated focus on the women that is part of the traditional system.

Anthropological involvement in the Central American diarrheal disease control project.

The process of conducting applied anthropological work leading to health program development and evaluation is seldom described in the literature. This paper discusses the combination of factors which led to the involvement of anthropologists in the Central American Child Survival Project and how anthropological approaches are being used in the project. Ethnoclassification was used to illustrate the discrepancy between the proposed approach to treatment for dehydration produced by diarrheal disease and the actual beliefs and practices in 4 Central American communities. Techniques such as rapid, focused assessment using anthropological methods of data collection and presentation are discussed, as are strategies for presenting this information to health program planners and administrators.