Prevalência de comorbidades em pacientes com megaesôfago chagásico / Prevalence of comorbidities in patients with chagasic megaesophagus

ABSTRACT Objective: This study aimed to evaluate the prevalence of some epidemiologically important comorbidities in patients with Chagas megaoesophagus in relation to the population without megaoesophagus, and whether this condition would be a protective or a risk factor for the conditions analysed. Methods: This observational descriptive study collected data from the medical records of patients with a previous diagnosis of megaoesophagus (timing: from 2005 to 2020). The patients were divided by age into a general (all ages) and an older group (aged 60 years or more). Associations were searched for four main areas/systems/involvements: cardiovascular, respiratory, endocrine and neurological. Results: The general group included 546 patients and the older group included 248 patients. As for the prevalence of comorbidities in the general group, the three most prevalent diseases were hypertension, with 44.3% (CI95%: 40.21-48.51%); dyslipidaemia, with 17.8% (CI95%: 14.79-21.19%); and heart failure, with 15.2% (CI95%: 12.43-18.45%). Similar to that in the general group, the most prevalent comorbidities in the group of older patients were hypertension, dyslipidaemia, and heart failure. Conclusion: Systemic arterial hypertension, dyslipidaemia, and heart failure were the most prevalent comorbidities in this population. The lower prevalence of diabetes mellitus and Alzheimer's disease suggests the association of enteric nervous system denervation and requires further investigation.

RESUMO Objetivo: Este estudo teve como objetivo avaliar a prevalência de algumas comorbidades epidemiologicamente importantes em pacientes com megaesôfago chagásico em relação à população sem o megaesôfago e se essa condição seria um fator protetor ou de risco para as condições analisadas. Métodos: Este estudo descritivo observacional coletou dados de prontuários de pacientes com diagnóstico prévio de megaesôfago (período: de 2005 a 2020). Os pacientes foram divididos por idade em um grupo geral (todas as idades) e um grupo idoso (60 anos ou mais). Foram pesquisadas associações para quatro áreas/sistemas/envolvimentos principais: cardiovascular, respiratório, endócrino e neurológico. Resultados: O grupo geral incluiu 546 pacientes e o grupo idosos incluiu 248 pacientes. Quanto à prevalência de comorbidades no grupo geral, as três doenças mais prevalentes foram hipertensão, com 44,3% (IC95%: 40,21-48,51%); dislipidemia, com 17,8% (IC95%: 14,79-21,19%); e insuficiência cardíaca, com 15,2% (IC95%: 12,43-18,45%). Assim como no grupo geral, as comorbidades mais prevalentes no grupo de idosos foram hipertensão, dislipidemia e insuficiência cardíaca. Conclusão: Hipertensão arterial sistêmica, dislipidemia e insuficiência cardíaca foram as comorbidades mais prevalentes nessa população. A menor prevalência de diabetes mellitus e doença de Alzheimer sugere uma associação de denervação do sistema nervoso entérico e requer mais investigação.

Presença de mutações no gene BRAF e outros oncogenes e associação com características clínicas e epidemiológicas em pacientes com melanoma metastático / Presence of risk in the BRAF gene and other oncogenes and association with clinical and epidemiological characteristics in patients with metastatic melanoma

Embora o melanoma seja representado por apenas cerca de 5% dos casos de tumores malignos de pele, é responsável pela ampla maioria de óbitos relacionados a tumores cutâneos. Seu desenvolvimento está principalmente associado à presença de mutações em oncogenes específicos, como BRAF, c-KIT e PDGFRA, os quais estão relacionados ao metabolismo celular. OBJETIVOS: Avaliar retrospectivamente a presença de mutações nos genes BRAF (éxons 15), C-KIT (éxons 9,11,13 e 17) e PDGFRA (éxons 12 ,14 e 18) e correlacionar os resultados com as características clínicas e epidemiológicas e desfecho dos pacientes. METODOLOGIA: Foi realizado um estudo retrospectivo de 94 pacientes com melanoma metastático atendidos no Hospital Amaral Carvalho entre os anos de 2015 a 2022, de acordo com as seguintes variáveis: idade ao diagnóstico, gênero, cor, local do tumor primário, local de metástase, subtipo histológico de melanoma, dosagem de LDH, positividade para marcadores de imuno-histoquímica, espessura, presença de ulceração, metástase no linfonodo ao diagnóstico do tumor primário, espessura Breslow, classificação Clark, índice mitótico e desfecho (óbito, sobrevida). RESULTADOS: A maioria dos pacientes eram do sexo masculino (52,1%), de cor branca (97,9%) e com idade acima de 60 anos (42,5%). O subtipo histológico mais encontrado foi o extensivo superficial (42,5%), sendo os membros inferiores o local mais acometido (35,1%). O nível IV de Clark (39,4%) e índice de Breslow acima de 4mm (33,0%) foram os mais prevalentes. A maior parte dos tumores não apresentou ulceração (53,2%) e mais da metade dos pacientes apresentou mais de uma mitose por mm² (47,9%). A dosagem de desidrogenase láctica (LDH) se manteve dentro da normalidade na maioria dos pacientes no momento do diagnóstico (43,6%) e no surgimento de metástases (30,9%). Todos os pacientes apresentaram ao menos uma metástase, sendo os linfonodos regionais o local de maior incidência. A maioria dos pacientes faleceu em decorrência da doença (66,0%). A análise de BRAF apresentou significância estatística para as variáveis idade ao diagnóstico (p= 0,0085), tipo histológico (p= 0,048) e nível de Clark (p= 0,0290). A mediana de sobrevivência para pacientes com mutações em BRAF foi de 62 meses e 50 meses para aqueles que não apresentaram mutações. Não foram encontradas significâncias estatísticas entre c-KIT e as variáveis analisadas. A mediana de sobrevivência para pacientes com mutações em c-KIT foi de 38 meses e 70 meses para aqueles que não apresentaram mutações. CONCLUSÕES: A presença de mutação em BRAF esteve associada à menor idade e menores índices de Clark, e relacionada à ligeira maior sobrevida. O contrário foi observado para mutações em c-KIT, apesar da ausência de significância estatística: uma ligeira menor sobrevida foi observada em pacientes mutados. O LDH não esteve bem correlacionado à presença do melanoma metastático ao se apresentar normal na maioria dos casos. Grande parte dos pacientes tiveram o tumor primário localizado nos membros inferiores, diferentemente do relatado por outros estudos, e apesar de não significante, os tumores de tronco foram em sua maioria mutados para BRAF, e o oposto observado em membros inferiores e superiores. Assim, o papel prognóstico da mutação em BRAF na progressão da doença é ainda controverso. Tais dados podem fornecer mais informações para a adequação de protocolos de prevenção e tratamento de pacientes acometidos por melanoma.

INTRODUCTION: Although melanoma is represented by only about 5% of cases of malignant skin tumors, it is responsible for the vast majority of deaths related to skin tumors. Its development is mainly associated with the presence of mutations in specific oncogenes, such as BRAF, c-KIT and PDGFRA, which are related to cell metabolism. OBJECTIVES: Retrospectively evaluate the presence of mutations in BRAF (exons 15), C-KIT (exons 9,11,13 and 17) and PDGFRA (exons 12, 14 and 18) genes and correlate the results with the clinical and epidemiological characteristics and patient outcomes. METHODS: A retrospective study of 94 patients with metastatic melanoma treated at Hospital Amaral Carvalho between the years 2015 to 2022 was carried out, according to the following variables: age at diagnosis, gender, color, site of primary tumor, site of metastasis, histological subtype of melanoma, LDH dosage, positivity for immunohistochemical markers, thickness, presence of ulceration, lymph node metastasis at diagnosis of the primary tumor, Breslow thickness, Clark classification, mitotic index and outcome (death, survival). RESULTS: Most patients were male (52.1%), white (97.9%) and aged over 60 years (42.5%). The most common histological subtype was superficial extensive (42.5%), with the lower limbs being the most affected site (35.1%). Clark's level IV (39.4%) and Breslow thickness above 4mm (33.0%) were the most prevalent. Most tumors did not show ulceration (53.2%) and more than half of the patients had more than one mitosis per mm² (47.9%). The lactate dehydrogenase (LDH) dosage remained within the normal range in most patients at the time of diagnosis (43.6%) and at the onset of metastases (30.9%). All patients had at least one metastasis, with regional lymph nodes being the site with the highest incidence. Most patients died as a result of the disease (66.0%). BRAF analysis showed statistical significance for the variables age at diagnosis (p= 0.0085), histological type (p= 0.048) and Clark's level (p= 0.0290). Median survival for patients with BRAF mutations was 62 months and 50 months for those without mutations. No statistical significance was found between c-KIT and the analyzed variables. The median survival for patients with c-KIT mutations was 38 months and 70 months for those without mutations. CONCLUSIONS: The presence of a BRAF mutation was associated with younger age and lower Clark scores, and related to slightly longer survival. The opposite was observed for mutations in c-KIT, despite the absence of statistical significance: a slightly lower survival was observed in mutated patients. LDH was not well correlated with the presence of metastatic melanoma as it was normal in most cases. Most of the patients had the primary tumor located in the lower limbs, unlike what has been reported by other studies, and although not significant, the trunk tumors were mostly mutated to BRAF, and the opposite was observed in the lower and upper limbs. Thus, the prognostic role of the BRAF mutation in disease progression is still controversial. Such data may provide more information for the adequacy of prevention and treatment protocols for patients affected by melanoma.

Derivación y validación de una puntuación de riesgo de ingreso en la Unidad de Cuidados Intensivos para pacientes con COVID-19 / Derivation and validation of a risk score for admission to the Intensive Care Unit in patients with COVID-19

Fundamento: Identificar y validar una escala de riesgo de ingreso en las unidades de cuidados intensivos (UCI) en pacientes hospitalizados con enfermedad por coronavirus 2019 (COVID-19). Métodos: Realizamos una regla de derivación y otra de validación para ingreso en UCI, utilizando los datos de un registro nacional de cohortes de pacientes con infección confirmada por SARS-CoV-2 ingresados entre marzo y agosto del año 2020 (n = 16.298). Analizamos variables demográficas, clínicas, radiológicas y de laboratorio disponibles en el ingreso hospitalario. Evaluamos el rendimiento de la escala de riesgo mediante estimación del área bajo la curva de característica operativa del receptor (AROC). Utilizamos los coeficientes β del modelo de regresión para elaborar una puntuación (0 a 100 puntos) asociada con ingreso en UCI. Resultados: La edad media de los pacientes fue de 67 años; 57% varones. Un total de 1.420 (8,7%) pacientes ingresaron en la UCI. Las variables independientes asociadas con el ingreso en UCI fueron: edad, disnea, índice de comorbilidad de Charlson, cociente neutrófilos-linfocitos, lactato deshidrogenasa e infiltrados difusos en la radiografía de tórax. El modelo mostró un AROC de 0,780 (IC: 0,763-0,797) en la cohorte de derivación y un AROC de 0,734 (IC: 0,708-0,761) en la cohorte de validación. Una puntuación > 75 se asoció con una probabilidad de ingreso en UCI superior a un 30%, mientras que una puntuación < 50 redujo la probabilidad de ingreso en UCI al 15%. Conclusiós: Una puntuación de predicción simple proporcionó una herramienta útil para predecir la probabilidad de ingreso en la UCI con un alto grado de precisión (AU)

Background: This work aims to identify and validate a risk scale for admission to intensive care units (ICU) in hospitalized patients with coronavirus disease 2019 (COVID-19). Methods: We created a derivation rule and a validation rule for ICU admission using data from a national registry of a cohort of patients with confirmed SARS-CoV-2 infection who were admitted between March and August 2020 (n = 16,298). We analyzed the available demographic, clinical, radiological, and laboratory variables recorded at hospital admission. We evaluated the performance of the risk score by estimating the area under the receiver operating characteristic curve (AUROC). Using the β coefficients of the regression model, we developed a score (0 to 100 points) associated with ICU admission. Results: The mean age of the patients was 67 years; 57% were men. A total of 1,420 (8.7%) patients were admitted to the ICU. The variables independently associated with ICU admission were age, dyspnea, Charlson Comorbidity Index score, neutrophil-to-lymphocyte ratio, lactate dehydrogenase levels, and presence of diffuse infiltrates on a chest X-ray. The model showed an AUROC of 0.780 (CI: 0.763-0.797) in the derivation cohort and an AUROC of 0.734 (CI: 0.708-0.761) in the validation cohort. A score of greater than 75 points was associated with a more than 30% probability of ICU admission while a score of less than 50 points reduced the likelihood of ICU admission to 15%. Conclusion: A simple prediction score was a useful tool for forecasting the probability of ICU admission with a high degree of precision (AU)

Derivation and validation of a risk score for admission to the Intensive Care Unit in patients with COVID-19.

BACKGROUND: This work aims to identify and validate a risk scale for admission to intensive care units (ICU) in hospitalized patients with coronavirus disease 2019 (COVID-19). METHODS: We created a derivation rule and a validation rule for ICU admission using data from a national registry of a cohort of patients with confirmed SARS-CoV-2 infection who were admitted between March and August 2020 (N = 16,298). We analyzed the available demographic, clinical, radiological, and laboratory variables recorded at hospital admission. We evaluated the performance of the risk score by estimating the area under the receiver operating characteristic curve (AUROC). Using the ß coefficients of the regression model, we developed a score (0-100 points) associated with ICU admission. RESULTS: The mean age of the patients was 67 years; 57% were men. A total of 1420 (8.7%) patients were admitted to the ICU. The variables independently associated with ICU admission were age, dyspnea, Charlson Comorbidity Index score, neutrophil-to-lymphocyte ratio, lactate dehydrogenase levels, and presence of diffuse infiltrates on a chest X-ray. The model showed an AUROC of 0.780 (CI: 0.763-0.797) in the derivation cohort and an AUROC of 0.734 (CI: 0.708-0.761) in the validation cohort. A score of greater than 75 points was associated with a more than 30% probability of ICU admission while a score of less than 50 points reduced the likelihood of ICU admission to 15%. CONCLUSION: A simple prediction score was a useful tool for forecasting the probability of ICU admission with a high degree of precision.

Estudo preliminar para avaliação de sintomas e medicamentos prevalentes do "gênio epidêmico" da pandemia de Covid-19 no Brasil / Preliminary study for evaluation of prevalent symptoms and medicines of Covid-19 epidemic genius in Brazil

A Organização Mundial da Saúde (OMS) reconheceu a Covid-19 como uma nova doença infectocontagiosa em 12/01/2020, que logo tornou-se pandêmica. A Homeopatia historicamente apresenta bons resultados no tratamento de doenças epidêmicas, desde quando seu criador, Samuel Hahnemann, obteve êxito no tratamento, controle e profilaxia de uma epidemia de escarlatina no ano de 1799. O objetivo desse trabalho era o estudo retrospectivo de sintomas comuns da doença na sua primeira fase, buscando um grupo de sintomas característicos que indicassem os possíveis medicamentos do "gênio epidêmico". Para isso, utilizamos a metologia desenvolvida por Hahnemann e James Tyler Kent para o entendimento dos sintomas comuns da doença. Foram utilizados relatos de casos de 27 pacientes com Covid-19 confirmados laboratorialmente enviados por médicos homeopatas em diversas regiões do Brasil. Os sintomas mais característicos encontrados foram: fraqueza intensa, febre baixa, tosse seca, sudorese profusa noturna, cefaleia incaracterística e ageusia/anosmia. Utilizando-se de várias técnicas de repertorização desses sintomas, chegou-se ao grupo de cinco medicamentos possíveis para o tratamento da doença: Arsenicum album, Bryonia alba, China officinalis, Chininum arsenicosum e Phosphorus.

The World Health Organization (WHO) recognized Covid-19 as a new infectious disease on 12th January of 2020, which soon became a pandemic. Homeopathy historically presents good results in the treatment of epidemic diseases, since the time when its creator, Samuel Hahnemann, was successful in the treatment, control and prophylaxis of a scarlet fever epidemic in the year of 1799. The objective of this work was the retrospective study of common symptoms of disease in its first phase, looking for a group of characteristic symptoms that would indicate the possible remedies of the "epidemic genius". For this, we used the methodology developed by Hahnemann and James Tyler Kent to understand the common symptoms of the disease. Case reports of 27 patients with laboratory-confirmed Covid-19 sent by homeopathic physicians in different regions of Brazil were used. The most characteristic symptoms found were: intense weakness, low fever, dry cough, profuse night sweats, uncharacteristic headache and ageusia/anosmia. Using various techniques for repertorizing these symptoms, a group of five possible drugs for the treatment of the disease was reached: Arsenicum album, Bryonia alba, China officinalis, Chininum arsenicosum and Phosphorus.

Epidemiologia clínica homeopática: premissas e princípios para a elaboração da pesquisa clínica em homeopatia / Homeopathic clinical epidemiology: premises and principles for elaboration of clinical research in Homeopathy

A epidemiologia clínica se ocupa da prática clínica através do estudo da variação e dos determinantes da evolução das doenças, sendo indispensáveis os seus conhecimentos para o correto desenho, planejamento e execução dos diversos tipos de estudos clínicos. Dentre os pressupostos homeopáticos, a individualização do tratamento é uma condição indispensável para se atingir a eficácia e a efetividade da terapia, necessitando um período maior de acompanhamento para que os ajustes da similitude terapêutica globalizante sejam alcançados. A epidemiologia clínica homeopática associa as premissas e princípios da epidemiologia clínica aos da episteme homeopática, com o intuito de incrementar a qualidade metodológica da pesquisa clínica sem desrespeitar a racionalidade homeopática. Nessa revisão, abordamos as premissas e os princípios da epidemiologia clínica (homeopática), destacando os aspectos fundamentais para a elaboração de estudos epidemiológicos em homeopatia para os diversos tipos de doenças, incluindo as epidemias.

Clinical epidemiology deals with clinical practice through the study of variation and the determinants of the evolution of diseases, its knowledge being indispensable for the correct design, planning and execution of the different types of clinical studies. Among the homeopathic assumptions, the individualization of treatment is an indispensable condition to reach the efficacy and effectiveness of the therapy, requiring a longer period of follow-up so that the adjustments of the globalizing therapeutic similarity are achieved. Homeopathic clinical epidemiology associates the premises and principles of clinical epidemiology with those of homeopathic episteme, with the aim of increasing the methodological quality of clinical research without disrespecting homeopathic rationality. In this review, we discuss the premises and principles of (homeopathic) clinical epidemiology, highlighting the fundamental aspects for the elaboration of epidemiological studies in homeopathy for the different types of diseases, including epidemics.

Caracterización clínico epidemiológica de pacientes en edad pediátrica ingresados en centros de aislamiento de Cienfuegos / Clinical-epidemiological characterization of pediatric patients admitted to isolation centers of Cienfuegos province

Introducción: La población pediátrica no ha sido las más vulnerable a laCOVID-19. La vigilancia epidemiológica estricta y las estrategias tomadas, permiten identificar y realizar análisis clínico epidemiológico en esta población. Objetivo: Caracterizar desde la óptica clínica y epidemiológica a pacientes pediátricos ingresados en centros de aislamiento. Métodos: Estudio descriptivo y transversal en 316 infantes sospechosos de contactos de personas con COVID-19, edades entre 1 y 18 años e ingresados en los centros de aislamiento de Cienfuegos, desde el 11 de marzo al 30 de junio de 2020.Las variables: edad, sexo, casos sospechosos o contactos, mes de ingreso, sintomatología clínica y casos confirmados. Los datos se expresaron en valores absolutos y relativos. Resultados: Fueron sospechosos 36,7 por ciento niños, 63,3 por ciento contactos; 96,9 por ciento fueron remitidos desde sus áreas de salud. Solo 5 (1,6 por ciento) niños fueron confirmados con la enfermedad y todos tuvieron evolución favorable. Predominaron las edades de 5 a 9 años y de 15 a 18 años con 24,4 y 24,7 por ciento, respectivamente, sin diferencia de género;64,9 por ciento fueron asintomáticos. Los síntomas clínicos más frecuentes fueron: tos (56,8 por ciento) y fiebre (55,9 por ciento). Solo 9 (8,1 por ciento)con dificultad respiratoria. Conclusiones: La enfermedad en la población pediátrica de la provincia Cienfuegos no constituye un problema de salud por el bajo porcentaje de niños confirmados con la enfermedad en los centros de aislamiento. Se reafirma que una de las formas de transmisión es de hombre a hombre y es el aislamiento fundamental para el control y diagnóstico(AU)

Introduction: The pediatric population has not been the most vulnerable to COVID-19. Strict epidemiological surveillance and the strategies taken, allow to identify and perform a clinical-epidemiological analysis in this population. Objective: Characterize from the clinical and epidemiological points of view pediatric patients admitted to isolation centers. Methods: Descriptive and cross-sectional study of 316 infants who were suspected cases or contacts of people with COVID-19, in ages from 1 to 18 years and who were admitted to the isolation centers of Cienfuegos province, from March 11 to June 30, 2020. The variables used were: age, sex, suspected cases or contacts, month of admission, clinical symptomatology, and confirmed cases. The data were expressed in absolute and relative values. Results: 36.7 percent children, and 63.3 percent contacts were suspected; 96.9 percent were referred from their health areas. Only 5 (1.6 percent) children were confirmed with the disease and all had favorable evolution. The ages from 5 to 9 and from 15 to 18 years predominated with 24.4 percent and 24.7 percent, respectively, without gender difference; 64.9 percent were asymptomatic. The most common clinical symptoms were: cough (56.8 percent) and fever (55.9 percent). Only 9 patients (8.1 percent) had respiratory distress. Conclusions: This disease in the pediatric population of Cienfuegos province is not a health problem because of the low percentage of children confirmed with the COVID-19 in isolation centers. It is confirmed that one of the forms of transmission is person-to-person and isolation is vital for control and diagnosis(AU)

Differentiated thyroid cancer clinical trends in Quito, Ecuador / Tendencias clínicas del cáncer diferenciado de tiroides en Quito, Ecuador

Introduction.Thyroid cancer is currently the first most common cancer in women in Ecuador. This study aimed to assess the changes in clinical presentation and diagnosis of differentiated thyroid cancer at a third level hospital in Quito, Ecuador.Methods and Materials.This is a retrospective case series performed in three consecutive periods from 1990 to 2019 at a tertiary level hospital, in Quito, Ecuador. The clinical records of 875 patients who had been diagnosed and surgically treated for differentiated thyroid cancer were reviewed. Demographic, clinical, imaging, and pathological data were collected and analyzed.Results. Significant trends toward older age, higher educational level, less palpable primary tumors, less palpable neck nodes, less distant metastases, more ultrasound, tomography and cytology exams, smaller primary tumors, more stage I patients, and more histological variant description, were found. Introduction.Thyroid cancer is currently the first most common cancer in women in Ecuador. This study aimed to assess the changes in clinical presentation and diagnosis of differentiated thyroid cancer at a third level hospital in Quito, Ecuador.Methods and Materials.This is a retrospective case series performed in three consecutive periods from 1990 to 2019 at a tertiary level hospital, in Quito, Ecuador. The clinical records of 875 patients who had been diagnosed and surgically treated for differentiated thyroid cancer were reviewed. Demographic, clinical, imaging, and pathological data were collected and analyzed.Results. Significant trends toward older age, higher educational level, less palpable primary tumors, less palpable neck nodes, less distant metastases, more ultrasound, tomography and cytology exams, smaller primary tumors, more stage I patients, and more histological variant description, were found.

Introducción. El cáncer de tiroides es actualmente el cáncer más frecuente en la mujer en Ecuador. El presente estudio ha tenido como objetivo evaluar los cambios en la presentación clínica y el diagnóstico del cáncer diferenciado de tiroides en un hospital de tercer nivel de Quito, Ecuador. Material y Métodos. El presente es un estudio retrospectivo de casos realizado en tres períodos consecutivos desde 1990 a 2019 en un hospital del tercer nivel en Quito, Ecuador. Los expedientes clínicos de 875 pacientes tratados quirúrgicamente por un cáncer diferenciado de tiroides fueron revisados. Los datos demográficos, clínicos, de imagen y patología fueron extraídos y analizados. Resultados. Se encontraron tendencias significativas hacia una edad más avanzada, nivel educativo más alto, menos tumores palpables, menos adenopatías regionales palpables, menos metástasis a distancia, más exámenes de ultrasonido y tomografía, más estudios de citología, más tumores pequeños y pacientes con estadío I y más descripciones de las variantes histológicas. Conclusiones. El cáncer de tiroides no sólo que ha aumentado continuamente en su frecuencia en los años recientes, sino que la presentación clínica, el manejo diagnóstico y terapéutico ha cambiado significativamente en las tres últimas décadas.

Fenotipos clínicos de la enfermedad pulmonar obstructiva crónica en los pacientes atendidos en el Hospital neumológico de La Habana / Clinical phenotypes of chronic obstructive pulmonary disease in patients treated at the Hospital Neumológico de La Habana

Introducción: La identificación de los fenotipos clínicos son claves en la modulación de la expresión clínica, para un tratamiento integrado de la EPOC. Objetivos: Caracterizar los fenotipos clínicos de la EPOC en los pacientes atendidos en el Hospital Neumológico Benéfico Jurídico. Métodos:Se realizó un estudio observacional descriptivo retrospectivo, en 172 pacientes con diagnóstico de EPOC, en el Hospital Neumológico Benéfico Jurídico durante el año 2017.Resultados: El 38,4 % de los pacientes tenían edad entre 70-79 años. Del total de pacientes, el 54,6 % eran del sexo masculino. El 52,9 % eran fumadores activos y el 41,3 % exfumadores. Aunque las diferencias no fueron significativas, la edad avanzada y el sexo masculino fueron más frecuentes en el fenotipo enfisematoso agudizador y agudizador bronquítico crónico. El tabaquismo activo fue más frecuente en el fenotipo enfisematoso agudizador. Todos los pacientes con el fenotipo agudizador bronquítico crónico tuvieron dos o más exacerbaciones, mientras que el enfisematoso agudizador se relacionó con una severidad grave de la EPOC (46,7 %). Conclusiones: El sexo masculino y la edad avanzada muestran una tendencia a relacionarse con el fenotipo enfisematoso agudizador y agudizador bronquítico crónico, mientras que el tabaquismo activo es más frecuente en el fenotipo enfisematoso agudizador. El fenotipo agudizador bronquítico crónico se relaciona con mayores exacerbaciones y el enfisematoso agudizador con una mayor severidad de la EPOC.

Introduction: The identification of clinical phenotypes are key in the modulation of clinical expression, for an integrated treatment of COPD. Objectives: To characterize the clinical phenotypes of COPD in patients treated at the Hospital Neumológico Benéfico Jurídico. Methods: A retrospective descriptive observational study was carried out in 172 patients with a diagnosis of COPD at the Hospital Neumológico Benéfico Jurídico in 2017. Results: 38.4 % of the patients were between 70-79 years of age. Of the total number of patients, 54.6 % were male. 52.9 % were active smokers and 41.3 % ex-smokers. Although the differences were not significant, advanced age and male sex were more frequent in the exacerbator emphysematous and chronic bronchial exacerbator phenotype. Active smoking was more frequent in the exacerbating emphysematous phenotype. All patients with the chronic bronchial exacerbator phenotype had two or more exacerbations, while exacerbation emphysematous was associated with severe severity of COPD (46.7 %). Conclusions: Male sex and advanced age show a tendency to be related to the exacerbating emphysematous phenotype and chronic bronchitis exacerbator, while active smoking is more frequent in the exacerbating emphysematous phenotype. The chronic bronchitis exacerbator phenotype is related to greater exacerbations and exacerbation emphysematous with a greater severity of COPD

Valoración clínica del riesgo, interpretación y utilidad práctica / Clinical risk assessment, interpretation and practical utility

Los clínicos que observan la evidencia para una mejor atención de sus pacientes, deberían familiarizarse no sólo con algunas herramientas de lectura crítica de la literatura biomédica, sino que también con algunos conceptos epidemiológicos y herramientas estadísticas de utilidad que permiten valorar la validez de estos estudios. Nos referimos de forma especial a las medidas de asociación y de impacto que permiten resumir información estadística recogida de los artículos en cuestión, a modo de resumen de datos y análisis e interpretación de resultados, tanto de significación estadística como clínica. Entendemos que esto no es fácil ya que se trata de conceptos áridos y a veces incomprensibles; sino que porque además, no es común que el personal sanitario tenga incorporado el razonamiento probabilístico; y porque finalmente, la manera en que se informan este tipo de resultados no es la más didáctica que pudiese ser. Sin embargo, dada la progresiva proliferación y cada vez mayor disponibilidad de publicaciones científicas, se hace cada vez más imprescindible conocer y entender estos términos y su utilidad en la práctica clínica. Es por ello, que el objetivo de este manuscrito es describir los conceptos relacionados con la valoración del riesgo, conocer la modalidad de cálculo de las principales medidas de asociación y de impacto; así como también, su interpretación y aplicación práctica.

Clinicians who observed the evidence for better care of their patients, should be familiar not only with some tools of critical literature reading of biomedical articles, but also with some epidemiological concepts and statistical tools that are useful to assess the validity of these studies. We are referring particularly to the measures of association and impact which permit us the ability to summarize statistical information from the articles concerned, as a summary of data and analysis and interpretation of results with both statistical and clinical significance. We understand that this is not easy because these are dry concepts, and furthermore, it is rare that health staff have incorporated probabilistic reasoning, and because ultimately, the way these results are reported is not the most didactic and practical. However, given the increasing proliferation and availability of scientific publications, it becomes more and more essential to understand these concepts and their usefulness in clinical practice. Therefore, the aim of this paper is to describe the theoretical concepts for understanding the importance of risk analysis, to know the method of calculation of the main measures of association and impact used in clinical research, as well as its interpretation and practical application in different types of study designs.

Los sesgos en investigación clínica / Bias in clinical research

Uno de los mayores dilemas en investigación es la ocurrencia de errores, los que pueden darse por efecto del azar o de forma sistemática. Es así como, se puede considerar que existe sesgo cuando en el curso de una investigación se comete un error de forma sistemática, es decir no aparece como un hecho aleatorio o por efecto del azar. Los sesgos pueden ocurrir por un sinnúmero de causales; pero en términos generales, se acepta que los más frecuentes y quizás los de mayor relevancia son aquellos debidos al observador, a lo que se observa y a aquello con lo que se observa. Dicho de otra forma, el que mide, lo que se mide y con que se mide. Otro considerando a tener en cuenta es que un sesgo puede ocurrir en cualquier etapa del curso de una investigación, desde la planificación a la presentación de resultados y la publicación ulterior de estos. Por todo ello, el objetivo de este artículo es describir los conceptos que permitan comprender la importancia de los sesgos, conocer los más frecuentes en investigación clínica, su asociación con los distintos tipos de diseños de investigación y las estrategias que permiten minimizarlos y controlarlos.

One of the biggest dilemmas in clinical research is the occurrence of errors, which can occur by chance or systematic practice. Thus, we can consider that there is bias when in the course of an investigation a systematical error occurs and it is not listed as a random occurrence or by chance. Biases can occur for different causes, but it is generally accepted that the most common and perhaps the most important are those due to the observer, what is observed, and that with which it is observed. In other words, who measured, what is measured, and the instrument that is being used to measure. Another consideration to keep in mind refers to the concept that bias can occur at any stage of the course of an investigation, from the initial planning through the analysis and the results presentation and it subsequent publication. Therefore, the purpose of this paper is to describe the concepts for understanding the importance of the biases, knowing the most common biases in clinical research and its association with different types of research designs as well as the strategies to prevent and control it.

Aproximación epistemológica a las ciencias que soportan las prácticas basadas en la evidencia: anotaciones críticas / Epistemological approach to the sciences that support evidense-based practice / Aproximação epistemológica às ciências que suportam as práticas baseadas na evidência: anotações críticas

Presentamos en este artículo de reflexión un abordaje epistemológico a las disciplinas científicas que soportan las prácticas basadas en la evidencia: para ello se toma como modelo a la epidemiología clínica como proveedora de conocimiento para la medicina que basada en la evidencia. Se problematiza la idea de progreso que plantean estas prácticas en su enunciación. Se resaltan las inconveniencias de la importación ciega de los métodos de la física y la química para estudiar los fenómenos de la vida (lo humano allí incluido). Además se revisa críticamente la definición del objeto de la epidemiología clínica (el enfermo) subrayando algunas deficiencias en su marco conceptual. Se concluye planteando las limitaciones que esta propuesta presenta, lo cual disminuye su alcance explicativo y su coherencia interna.

We present in this reflection article, an epistemological approach to scientific disciplines that support evidence-based practices: for it, the clinical epidemiology modeled was selected as a provider of knowledge to evidence-based medicine.The idea of progress proposed by these practices in their enunciation is problematized. The inconveniences of blind import methods of physics and chemistry to study the phenomena of the life (human there included) are highlighted. Also,a critically review of the definition of the object of clinical epidemiology (the patient) highlighting some shortcomings in its conceptual framework. We conclude by asking the limitations in this proposal, which decreases its explanatory scope and internal consistency.

Apresentamos neste texto de reflexão uma abordagem epistemológica das discipli-nas científicas que suportam as práticas baseadas na evidência: para tanto, se toma como modelo à epidemiologia clínica como provedora de conhecimento para a medicina baseada na evidência. Problematiza se a ideia de progresso que propõem essas práticas em seu enunciado. Ressaltam-se as inconveniências da importação cega dos métodos da física e da química para estudar os fenómenos da vida (o humano aí incluso). E se revisa criti-camente a definição do objeto da epidemiologia clínica (o enfermo) sublinhando algumas deficiências em seu marco conceitual. Conclui-se propondo as limitações que esta proposta apresenta, o que diminui seu alcance explicativo e sua coerência interna.

Uso de tests diagnósticos en la práctica clínica (Parte 2): Aplicación clínica y utilidad de un test diagnóstico / Clinical use of diagnostic tests (Part 2): Clinical application and usefulness of a diagnostic test

La utilidad clínica de un test diagnóstico se califica de acuerdo a la magnitud en la que éste contribuye a modificar la probabilidad pre test de ocurrencia de un determinado diagnóstico. Para tales efectos, el cálculo y aplicación de razones de verosimilitud (likelihood ratios, LR) constituye una herramienta de gran utilidad. Cada resultado posible de un test posee un LR, a partir del cual es posible estimar cuánto aumenta o disminuye la probabilidad pre test, permitiendo al clínico descartar un diagnóstico, confirmarlo o bien continuar su investigación mediante la solicitud de nuevos exámenes. En la primera parte del presente artículo se analizaron las propiedades de un test diagnóstico (validez, reproducibilidad y seguridad). En esta segunda parte se ilustra el sustrato teórico subyacente al concepto de LR, se explica su metodología de cálculo y se describe su aplicación clínica.

The clinical usefulness of a diagnostic test is determined by the extent to which it helps to modify the pretest probability of occurrence of a certain diagnosis. For this purpose, the calculation and application of likelihood ratios (LR) is a very useful tool. Every possible result of a test has a LR, which allows for an estimation of the magnitude by which the pretest probability increases or decreases, thereby helping the physician rule out, confirm, or continue investigating a diagnosis with new tests. In the first part of this article the properties of a diagnostic test (validity, reproducibility and safety) were analyzed. This second part illustrates the theoretical background underlying the concept of LR, explains the methodology for calculating them and describes their clinical application.

Uso de tests diagnósticos en la práctica clínica (Parte 1): análisis de las propiedades de un test diagnóstico / Clinical use of diagnostic tests (Part 1): analysis of the properties of a diagnostic test

Diagnostic tests are widely used in clinical practice. Qualitative analysis of diagnostic test properties (validity, reproducibility and safety) has been systematized using clinical epidemiology tools that have introduced a series of concepts such as sensitivity, specificity and predictive values. Based on data reported by a clinical investigation, the present article illustrates the theoretical background underlying these concepts, explains the methodology for their calculation, and analyzes their main strengths and limitations. A second article (Part 2: Clinical application and usefulness of a diagnostic test), describes the manner in which information provided by a test should be applied in order to correctly resolve a clinical dilemma.

Los tests diagnósticos constituyen herramientas complementarias ampliamente utilizadas en la práctica clínica. La Epidemiología Clínica ha sistematizado el análisis cualitativo de sus propiedades (validez, repro-ducibilidady seguridad) mediante la introducción de una serie de conceptos tales como sensibilidad, especificidad y valores predictores. En base a los datos aportados por una investigación clínica, el presente artículo ilustra el sustrato teórico subyacente a los conceptos anteriormente mencionados, detalla su forma de cálculo y analiza sus principales fortalezas y limitaciones. En un segundo artículo (Parte 2: Aplicación clínica y utilidad de un test diagnóstico) se describe la forma en que la información aportada por una prueba debe ser aplicada correctamente en la resolución de un dilema clínico.

Confiabilidad de los resultados de la investigación odontológica venezolana disponible en un repositorio de publicaciones digitales en línea: aplicabilidad en el marco de la práctica clínica basada en evidencia / Reliability of dental research results Venezuelan available in a repository of online digital publications: applicability in the context of evidence-based clinical practice

Determinar el nivel de confiabilidad de los artículos odontológicos publicados en revistas científicas nacionales y disponibles en el repositorio de publicaciones digitales en línea "SciELO Venezuela" al cierre del primer trimestre de 2009. Se seleccionaron en SciELO Venezuela los trabajos originales enmarcados en el área de las ciencias odontológicas atendiendo a criterios previamente establecidos, determinándose la cantidad de estudios observacionales y experimentales. Asimismo, se obtuvo la proporción de ensayos clínicos controlados aleatorizados en relación al volumen total de trabajos analizados.113 artículos cumplieron con los criterios de inclusión. De ellos, 88,5% correspondieron a estudios epidemiológicos observacionales, 7,1% a estudios epidemiológicos experimentales y 4,4% a ensayos clínicos no controlados. Adicionalmente, 7 de esos 113 trabajos se categorizaron como ensayos clínicos controlados aleatorizados. En la investigación epidemiológica venezolana desarrollada en el campo de las ciencias odontológicas predominan los estudios observacionales, que si bien pueden proporcionar evidencia confiable, no son concluyentes en muchos casos, por lo que se requiere de estudios más robustos como los ensayos clínicos controlados aleatorizados capaces de generar evidencia válida. Esto contribuiría a una toma de decisiones clínicas y gerenciales más efectiva, e incluso a una mejor definición de políticas públicas de salud bucal

To determine the level of reliability of dental articles published in national scientific journals and available in the online repository of digital publications "SciELO Venezuela" at the end of first quarter 2009. Were selected in SciELO Venezuela framed original works in the dental sciences field according to previously established criteria, by determining itself the quantity of observational and experimental studies. Also, it was obtained the proportion of randomized controlled trials in relation to total volume of works reviewed. 113 articles met the inclusion criteria. Of them, 88.5% were observational epidemiological studies, 7.1% experimental epidemiological studies and 4.4% no controlled clinical trials. Additionally, 7 of 113 works were categorized as randomized controlled trials. In the epidemiological Venezuelan research developed in the dental sciences field predominate the observational studies, that although can provide reliable evidence, are not conclusive in many cases, reason why are required more robust studies like the randomized controlled trials able to generate valid evidence. This would contribute to a clinical and management decision-making more effective, and even to one better definition of public policies in oral health

Parasitología Basada en Evidencias: Una Nueva Filosofía en el Estudio y Manejo de las Enfermedades Parasitarias / Evidence Based Parasitology: A New Philosophy in the Study and Management of Parasitic Diseases

En el presente artículo de revisión se describen los principios básicos que dieron origen a una nueva filosofía de trabajo en la medicina clínica a partir de los conceptos de la epidemiología aplicada en dicha área, la Medicina Basada en Evidencias, y el potencial desarrollo de áreas integradas como la Parasitología Basada en Evidencias, que se constituye ahora como una nueva filosofía en el estudio y manejo de las enfermedades parasitarias.

This review article describes the basic principles that gave rise to a new philosophy of working in clinical medicine from the concepts of applied epidemiology in this area, evidence-based medicine, and integrated area development potential as Evidence Based Parasitology, which is now established as a new philosophy in the study and management of parasitic diseases.

Validez, seguridad y cociente de verosimilitud de los métodos tiras reactivas para orina y examen microscópico del sedimento urinario en el diagnóstico de hematuria enzoótica bovina / Validity, Accuracy and Coefficient of Probability of the Test Urine Reactive Strips and Microscopic Examination of the Urinary Sediment in the Diagnosis of Bovine Enzootic Hematuria

Fueron evaluados los resultados de paneo de 575 bovinos provenientes de once fincas del municipio Campo Elías, Mérida, Venezuela, a objeto de conocer la validez, seguridad y coeficiente de verosimilitud de las pruebas tiras reactivas para orina (TR) y examen microscópico del sedimento urinario (EMSU), opciones utilizadas como apoyo en el diagnóstico de Hematuria Enzoótica Bovina (HEB), para así delinear estrategias que permitan enfrentar la problemática en los rebaños. Los datos fueron comparados individual y en conjunto (paralelo y en serie) con los resultados de la evaluación anatomopatológica posmortem de 94 animales enfermos, lo que se consideró prueba estándar de oro. El análisis de las evidencias demuestra: {i} alto grado de validez, derivado de la alta sensibilidad (Sn) y especificidad (Es); {ii} excelente nivel de seguridad, medido mediante valores de predicción (VP+, VP-), para una prevalencia aparente del 16,34% y; {iii} extraordinario coeficiente de verosimilitud positivo (RV+) y negativo (RV-). Además, se discute la dificultad de comparar o extrapolar investigaciones precedentes ante la ausencia de datos, como: punto de corte en la conceptualización del término hematuria microscópica, valores de predicción y prevalencia de HEB, entre otros. Se concluye que bajo las condiciones existentes en la zona de estudio, el método TR resulta suficiente para la confirmación de los casos clínicos presuntivos de HEB. Caso contrario, al requerir descartar la enfermedad debe recurrirse directamente al EMSU; además, se define que la utilización en paralelo de ambos test posee características equivalentes a prueba estándar de oro. En virtud de tales evidencias se propone un algoritmo de trabajo a seguir para el diagnóstico temprano de los rebaños amenazados por el consumo del Pteridium, dicho patrón requiere de evaluaciones futuras.

Screning results of 575 bovines from eleven farms of the Campo Elías Municipality, Mérida State, Venezuela, were evaluated with the intention of knowing the validity, security and coefficient of probability of the tests urine reactive dip strips (URS) and microscopic examination of the urinary sediment (USME) as used options to support the diagnosis of Bovine Enzootic Hematuria (BEH), also in order to delineate strategies to face the problematic in the herds. The data were compared individual and altogether (parallel and in series) with the results of posmortem histophatological evaluation of 94 ill animals, it was considered a standard gold test. The analysis of the evidences demonstrates: (i) high validity degree, derivative of the high sensitivity (Sn) and specificity (Sp); (II) excellent level of security, measured trough values of prediction (PV+, PV-), for an apparent prevalence of 16.34% and; (III) extraordinary coefficient of positive probability (VR+) and negative (VR-). In addition, it is discussed the difficulty to compare or to extrapolate preceding investigations when there is not data, such as: cut off point in the definition of the microscopic hematuria term, values of prediction and prevalence of BEH, among others. One concludes that under the existing conditions in the zone of study, the URS method is sufficient for the confirmation of the clinical cases of BEH. On the other hand, when requiring discarding the disease is necessary to go directly to the USME; moreover, it is defined that the use in parallel of both of the test are equivalent to a standard gold test. As a result of such evidences a work algorithm is proposed to be followed in the early diagnosis of the herds threatened by the consumption of the Pteridium; this pattern requires futures evaluations.

Epidemiologia Clínica

Videoaula que aborda os objetivos da epidemiologia clínica e sua aplicação na prática dos profissionais das equipes de saúde da família.