Rentabilidad de la ratio angiogénica en el seguimiento de gestantes de alto riesgo de preeclampsia precoz tratadas con ácido acetilsalicílico / Profitability of the angiogenic ratio in the follow-up of pregnant women at high risk of early preeclampsia treated with acetylsalicylic acid

Objetivo: Evaluar el valor predictivo negativo de la ratio antigénica y conocer su rentabilidad para descartar preeclampsia precoz en pacientes de alto riesgo de desarrollarla, con profilaxis de ácido acetilsalicílico. Métodos: Se realizó un estudio descriptivo transversal que recogió a las gestantes con cribado de preeclampsia precoz de alto riesgo (384 gestantes) en el Hospital Santa Lucía durante el año 2021, para lo que se usó test Elecsys® tabulado a un riesgo mayor a 1/150 en primer trimestre, y que tomaran ácido acetilsalicílico antes de la semana 16, quedando en 368 gestantes vistas en las semanas 20, 26, 31 y 36. Se realizó biometría, ratio angiogénica y doppler. Resultados: La incidencia de preeclampsia precoz en la población fue 4 casos (incidencia 1,08 %). Son significativos por su alto valor predictivo negativo del 100 % de preeclampsia precoz: la ratio angiogénica mayor a 38 en la semana 26 y el doppler de las uterinas en semana 20 y 26. Conclusión: En gestaciones con cribado de alto riesgo de preeclampsia que tomen ácido acetilsalicílico, una ratio angiogénica menor a 38 en la semana 26, además de un doppler uterino normal en semana 20 y 26 permite reducir el seguimiento gestacional(AU)

Objective: Our main objective was to evaluate the negative predictive value of the angiogenic ratio and to know its profitability to rule out early preeclampsia in patients at high risk of early preeclampsia with acetylsalicylic acid prophylaxis. Methods: A cross-sectional descriptive study was carried out that included pregnant women with high-risk early preeclampsia screening (384 pregnant women) at the Santa Lucía Hospital during the year 2021, for which the Elecsys® test tabulated at a risk >1/ was used. 150 in the first trimester, and who take acetylsalicylic acid before week 16, leaving 368 pregnant women seen in weeks 20, 26, 31 and 36, with biometry, angiogenic ratio and Doppler performed. Results: The incidence of early preeclampsia in the population was 4 cases (incidence 1.08%). They are significant due to their high negative predictive value of 100% of early preeclampsia: Angiogenic ratio > 38 in week 26, uterine Doppler in weeks 20 and 26. Conclusion: Pregnancies with high risk screening for preeclampsia who take acid acetylsalicylic acid, an angiogenic ratio < 38 at week 26 in addition to a normal uterine Doppler at weeks 20 and 26 allows for reduced gestational follow-up(AU)

Predictive value of dynamic arterial elastance for vasopressor withdrawal: a systematic review and meta-analysis.

BACKGROUND: Dynamic arterial elastance (Eadyn) has been investigated for its ability to predict hypotension during the weaning of vasopressors. Our study focused on assessing Eadyn's performance in the context of critically ill adult patients admitted to the intensive care unit, regardless of diagnosis. MAIN BODY: Our study was conducted in accordance with the Preferred Reported Items for Systematic Reviews and Meta-Analysis checklist. The protocol was registered in PROSPERO (CRD42023421462) on May 26, 2023. We included prospective observational studies from the MEDLINE and Embase databases through May 2023. Five studies involving 183 patients were included in the quantitative analysis. We extracted data related to patient clinical characteristics, and information about Eadyn measurement methods, results, and norepinephrine dose. Most patients (76%) were diagnosed with septic shock, while the remaining patients required norepinephrine for other reasons. The average pressure responsiveness rate was 36.20%. The synthesized results yielded an area under the curve of 0.85, with a sensitivity of 0.87 (95% CI 0.74-0.93), specificity of 0.76 (95% CI 0.68-0.83), and diagnostic odds ratio of 19.07 (95% CI 8.47-42.92). Subgroup analyses indicated no variations in the Eadyn based on norepinephrine dosage, the Eadyn measurement device, or the Eadyn diagnostic cutoff to predict cessation of vasopressor support. CONCLUSIONS: Eadyn, evaluated through subgroup analyses, demonstrated good predictive ability for the discontinuation of vasopressor support in critically ill patients.

Enhancing Cervical Cancer Screening with 7-Type HPV mRNA E6/E7 Testing on Self-Collected Samples: Multicentric Insights from Mexico.

Cervical cancer remains a significant public health issue, particularly in regions with low screening uptake. This study evaluates the effectiveness of self-sampling and the 7-type HPV mRNA E6/E7 test in improving cervical cancer screening outcomes among a referral population in Mexico. A cohort of 418 Mexican women aged 25 to 65, referred for colposcopy and biopsy due to abnormal cytology results (ASC-US+), participated in this study. Self-samples were analyzed using both the 14-type HPV DNA test and the 7-type HPV mRNA E6/E7 test. The study assessed the sensitivity, specificity, positive predictive value (PPV), and the necessity of colposcopies to detect CIN3+ lesions. Participant acceptability of self-sampling was also evaluated through a questionnaire. The 7-type HPV mRNA E6/E7 test demonstrated equivalent sensitivity but significantly higher specificity (77.0%) and PPV for CIN3+ detection compared to the 14-type HPV DNA test (specificity: 45.8%, p < 0.001). The use of the HPV mRNA test as a triage tool reduced the number of colposcopies needed per CIN3+ case detected from 16.6 to 7.6 (p < 0.001). Self-sampling was highly accepted among participants, with the majority reporting confidence in performing the procedure, minimal discomfort, and willingness to undertake self-sampling at home. Self-sampling combined with the 7-type HPV mRNA E6/E7 testing offers a promising strategy to enhance cervical cancer screening by improving accessibility and ensuring precise diagnostics. Implementing these app roaches could lead to a significant reduction in cervical cancer morbidity and mortality, especially in underserved populations. Future research should focus on the long-term impact of integrating these methods into national screening programs and explore the cost-effectiveness of widespread implementation.

Models for predicting the risk of illness in leprosy contacts in Brazil: Leprosy prediction models in Brazilian contacts.

OBJECTIVE: This study aims to develop and validate predictive models that assess the risk of leprosy development among contacts, contributing to an enhanced understanding of disease occurrence in this population. METHODS: A cohort of 600 contacts of people with leprosy treated at the National Reference Center for Leprosy and Health Dermatology at the Federal University of Uberlândia (CREDESH/HC-UFU) was followed up between 2002 and 2022. The database was divided into two parts: two-third to construct the disease risk score and one-third to validate this score. Multivariate logistic regression models were used to construct the disease score. RESULTS: Of the four models constructed, model 3, which included the variables anti-phenolic glycolipid I immunoglobulin M positive, absence of Bacillus Calmette-Guérin vaccine scar and age ≥60 years, was considered the best for identifying a higher risk of illness, with a specificity of 89.2%, a positive predictive value of 60% and an accuracy of 78%. CONCLUSIONS: Risk prediction models can contribute to the management of leprosy contacts and the systematisation of contact surveillance protocols.

Predictive value of glycoprotein DKK3 for early neurological deterioration after ischemic stroke.

OBJECTIVE: To explore the value of serum Dickkopf-3 (sDKK3) in predicting Early Neurological Deterioration (END) and in-hospital adverse outcomes in acute ischemic stroke (AIS) patients. METHODS: AIS patients (n = 200) were included and assessed by the National Institutes of Health Stroke Rating Scale. Serum Dkk3 levels were assessed by ELISA. END was defined as an increase of ≥ 4 points in NIHSS score within 72h. The biological threshold of sDKK3 level and END occurrence were predicted based on X-tile software. Primary outcomes were END and all-cause death, and the secondary outcome was ICU admission during hospitalization. The logistic regression model and Cox risk regression model were applied to evaluate the relationship between DKK3 level and END incidence, all-cause in-hospital mortality, and in-hospital adverse outcomes (ICU admission). RESULTS: During hospitalization, the incidence of END in patients with AIS was 13.0 %, and the mortality rate within 7 days after END was 11.54 % (3/26). In patients below the serum DKK3 cutoff (93.0 pg/mL), the incidence of END was 43.5 % (20/48). Patients with lower sDKK3 levels were associated with a 1.188-fold increased risk of developing END (OR = 1.188, 95 % CI 1.055‒1.369, p < 0.0001). However, there was no significant association with admission to the ICU. sDKK3 below the threshold (93.0 pg/mL) was a risk factor for death. CONCLUSION: Predictive threshold levels of serum DKK3 based on X-tile software may be a potential predictive biomarker of in-hospital END in patients with AIS, and low levels of DKK3 are independently associated with increased in-hospital mortality.

Complementarity of nutrition screening with Global Leadership Initiative on Malnutrition criteria for diagnosing malnutrition in critically ill patients: A comparison study of Nutritional Risk Screening 2002 and modified Nutrition Risk in the Critically Ill Score.

BACKGROUND AND AIM: Critical illness induces hypermetabolism and hypercatabolism, increasing nutrition risk (NR). Early NR identification is crucial for improving outcomes. We assessed four nutrition screening tools (NSTs) complementarity with the Global Leadership Initiative on Malnutrition (GLIM) criteria in critically ill patients. METHODS: We conducted a comparative study using data from a cohort involving five intensive care units (ICUs), screening patients for NR using NRS-2002 and modified-NUTRIC tools, with three cutoffs (≥3, ≥4, ≥5), and malnutrition diagnosed by GLIM criteria. Our outcomes of interest included ICU and in-hospital mortality, ICU and hospital length of stay (LOS), and ICU readmission. We examined accuracy metrics and complementarity between NSTs and GLIM criteria about clinical outcomes through logistic regression and Cox regression. We established a four-category independent variable: NR(-)/GLIM(-) as the reference, NR(-)/GLIM(+), NR(+)/GLIM(-), and NR(+)/GLIM(+). RESULTS: Of the 377 patients analyzed (median age 64 years [interquartile range: 54-71] and 53.8% male), NR prevalence varied from 87% to 40.6%, whereas 64% presented malnutrition (GLIM criteria). NRS-2002 (score ≥4) showed superior accuracy for GLIM-based malnutrition. Multivariate analysis revealed mNUTRIC(+)/GLIM(+) increased >2 times in the likelihood of ICU and in-hospital mortality, ICU and hospital LOS, and ICU readmission compared with the reference group. CONCLUSION: No NST exhibited satisfactory complementarity to the GLIM criteria in our study, emphasizing the necessity for comprehensive nutrition assessment for all patients, irrespective of NR status. We recommend using mNUTRIC if the ICU team opts for nutrition screening, as it demonstrated superior prognostic value compared with NRS-2002, and applying GLIM criteria in all patients.

Variáveis Clínicas e Laboratoriais na Admissão Hospitalar são Preditores de Fibrilação Atrial Nova em Pacientes Internados com Pneumonia por COVID-19 / Clinical and Laboratory Data Up on Hospital Admission are Predictors of New-Onset Atrial Fibrillation in Patients Hospitalized Due to COVID-19 Pneumonia

Resumo Fundamento Fibrilação atrial nova (FAN) ocorre em pacientes internados por COVID-19. Há controvérsias quanto ao valor preditivo de dados clínicos e laboratoriais à admissão hospitalar para ocorrência de FAN. Objetivos Analisar, à admissão hospitalar, variáveis com potencial preditivo para ocorrência de FAN em pacientes com pneumonia por COVID-19. Método Estudo observacional, retrospectivo, caso-controle. Foram avaliados prontuários eletrônicos de pacientes consecutivos ≥ 60 anos, hospitalizados com pneumonia por COVID-19 entre 1º de março e 15 de julho de 2020. Comparações feitas pelos testes `t' de Student ou qui-quadrado. Foi empregado modelo de risco proporcional de Cox para identificação de preditores de FAN. Considerou-se o valor de p < 0,05 como estatisticamente significativo. Resultados Entre 667 pacientes internados por COVID-19, 201 (30,1%) foram incluídos. FAN foi documentada em 29 pacientes (14,4%) (grupo 1). Grupo 2 foi composto por 162 pacientes que não apresentaram FAN. Dez pacientes excluídos por estarem em FA na admissão hospitalar. Houve diferenças entre os grupos 1 e 2, respectivamente, no tempo de permanência em UTI (11,1±10,5 dias vs. 4,9±7,5 dias; p=0,004), necessidade de ventilação invasiva (82,9% e 32,7%; p<0,001) e mortalidade hospitalar (75,9% vs. 32,1%; p<0,001). No modelo de Cox, idade > 71 anos (hazard ratio [HR]=6,8; p<0,001), leucometria ≤ 7.720 cels.μL-1 (HR=6,6; p<0,001), natremia ≤ 137 mEq.L-1 (HR=5,0; p=0,001), escore SAPS3 > 55 (HR=5,6; p=0,002) e desorientação (HR=2,5; p=0,04) foram preditores independentes de FAN. Conclusões FAN é uma arritmia comum em idosos hospitalizados com pneumonia por COVID-19. Parâmetros clínicos e laboratoriais avaliados na admissão são preditores de FAN durante internação.

Abstract Background New-onset atrial fibrillation (NOAF) occurs in patients hospitalized due to COVID-19. It is still unknown whether clinical and laboratory data assessed upon hospital admission have predictive value for NOAF. Objectives To analyze, upon hospital admission, variables with predictive potential for the occurrence of NOAF in patients with COVID-19 pneumonia. Methods Observational, retrospective, case-control study. Electronic medical reports of consecutive patients, 60 years of age or older, hospitalized due to COVID-19 pneumonia between March 1st and July 15th, 2020, were reviewed. Non-paired Student or chi-squared tests compared variables. A Cox proportional hazard model was employed to identify independent predictors of NOAF. P value < 0.05 was considered statistically significant. Results Among 667 patients hospitalized due to COVID-19, 201 (30.1%) fulfilled the inclusion criteria. NOAF was documented in 29 patients (14.4%), composing group 1. Group 2 was composed of 162 patients without NOAF. Ten patients were excluded due to the AF rhythm upon hospital admission. In groups 1 and 2, there were differences in overall in-hospital survival rate (24.1 % vs. 67.9%; p<0.001), length of stay in ICU (11.1 ± 10.5 days vs. 4.9 ± 7.5 days; p=0.004) and need for mechanical ventilation rate (82.9% vs. 32.7%; p<0.001). In the Cox model, age > 71 y/o (HR=6.8; p<0.001), total leukocyte count ≤ 7,720 cels.μL-¹ (HR=6.6; p<0.001), serum [Na+] ≤ 137 mEq.L-¹ (HR=5.0; p=0.001), SAPS3 score > 55 (HR=5.6; p=0.002), and disorientation (HR=2.5; p=0.04) on admission were independent predictors of NOAF. Conclusion NOAF is a common arrhythmia in elderly hospitalized patients with COVID-19 pneumonia. Clinical and laboratory parameters evaluated on admission have a predictive value for the occurrence of NOAF during hospitalization.

Prediction of duloxetine efficacy in addition to self-management in painful temporomandibular disorders: A randomised, placebo-controlled clinical trial.

BACKGROUND: Conditioned pain modulation (CPM) is a potential predictor of treatment response that has not been studied in temporomandibular disorders (TMD). OBJECTIVES: We conducted a randomised, double-blind, placebo-controlled trial (RCT) of duloxetine in addition to self-management (SM) strategies to investigate its efficacy to reduce pain intensity in painful TMD patients. Moreover, we investigated whether baseline CPM would predict the duloxetine efficacy to reduce TMD pain intensity. METHODS: Eighty participants were randomised to duloxetine 60 mg or placebo for 12 weeks. The primary outcomes were the change in the pain intensity from baseline to week-12 and CPM-sequential paradigm at baseline. Safety, physical and emotional functioning outcomes were also evaluated. RESULTS: Of 80 participants randomised, 78 were included in intention-to-treat analysis. Pain intensity decreased for SM-duloxetine and SM-placebo but did not differ between groups (p = .82). A more efficient CPM was associated with a greater pain intensity reduction regardless of the treatment group (p = .035). Physical and emotional functioning did not differ between groups, but adverse events (p = .014), sleep impairment (p = .003) and catastrophizing symptoms (p = .001) were more prevalent in SM-duloxetine group. CONCLUSION: This study failed to provide evidence of a beneficial effect of adding duloxetine to SM strategies for treatment of painful TMD. Nonetheless, this RCT has shown the feasibility of applying pain modulation assessment to predict short-term treatment response in painful TMD patients, which confirms previous finds that CPM evaluation may serve a step forward in individualising pain treatment.

Identificación con azul patente de ganglio centinela en cáncer de mama / Patent blue for identification of sentinel nodes in breast cancer

Resumen OBJETIVO: Describir las características sociodemográficas, clínicas y patológicas y los resultados obtenidos con la técnica de ganglio centinela con azul patente en la cirugía de cáncer de mama temprano. Además, reportar la experiencia en la identificación del ganglio centinela en cáncer de mama temprano con la técnica con azul patente al 2.5%. MATERIALES Y MÉTODOS: Estudio retrospectivo y analítico consistente en la evaluación de los expedientes clínicos de pacientes diagnosticadas con cáncer de mama temprano, sin sospecha clínica o radiológica de afectación axilar, atendidas entre junio de 2022 y junio de 2023 en el servicio de Ginecología Oncológica de la UMAE Hospital de Ginecoobstetricia, Centro Médico Nacional de Occidente del IMSS. El sitio de inyección del colorante fue subdérmico periareolar, los ganglios identificados se estudiaron en el transoperatorio. Se analizaron el porcentaje de identificación, las tasas de falsos negativos y el valor predictivo negativo del método. RESULTADOS: Se analizaron 95 procedimientos de biopsia de ganglio centinela. Solo se practicó la linfadenectomía axilar en las pacientes con metástasis en el ganglio centinela comprobada en el estudio transoperatorio y en las que no se identificaron ganglios teñidos por no migración del colorante. La edad promedio de las pacientes fue de 57.1 años límites 25 y 78 años. El tamaño del tumor fue menor a 3 cm. A 64 67% pacientes se les hizo la mastectomía en comparación con 31 a quienes se efectuó cirugía conservadora de mama 33%. Se estadificaron como IA 57 de las 95 pacientes; el subtipo molecular más frecuente fue compatible con luminal A en 49%. CONCLUSIONES: La biopsia del ganglio centinela, con azul patente, es una técnica rápida, sencilla, precisa y de bajo costo para identificar daño axilar en etapas tempranas del cáncer de mama. Lo aquí reportado son resultados que corresponden a una primera evaluación de la técnica en nuestro servicio.

Abstract OBJECTIVE: To describe the sociodemographic, clinical and pathological characteristics and results of the patent blue sentinel lymph node technique in early breast cancer surgery. And to report the experience in identifying the sentinel lymph node in early breast cancer using the 2.5% patent blue technique. MATERIALS AND METHODS: Retrospective and analytical study consisting of the evaluation of the clinical records of patients diagnosed with early breast cancer, without clinical or radiological suspicion of axillary involvement, seen between June 2022 and June 2023 at the Oncological Gynaecology Service of the UMAE Hospital de Ginecoobstetricia, Centro Médico Nacional de Occidente of the IMSS. The dye injection site was subdermal periareolar, and the identified lumps were examined in the transoperative period. The percentage of identification, false negative rates and negative predictive value of the method were analysed. RESULTS: Ninety-five sentinel node biopsies were analysed. Axillary lymphadenectomy was performed only in patients with sentinel lymph node metastasis confirmed at surgery and in those in whom no stained nodes were identified due to non-migration of the dye. The mean age of the patients was 57.1 years range 25 to 78 years. The tumour size was less than 3 cm. Sixty-four patients 67% underwent mastectomy, compared with 31 who underwent breast-conserving surgery 33%. Fifty-seven of the 95 patients were staged as AI; the most common molecular subtype was compatible with luminal A in 49%. CONCLUSIONS: Sentinel lymph node biopsy with patent blue is a rapid, simple, accurate and inexpensive technique for identifying axillary disease in early breast cancer. The results reported here represent an initial evaluation of the technique in our service.

Predictive value of glycoprotein DKK3 for early neurological deterioration after ischemic stroke

Abstract Objective To explore the value of serum Dickkopf-3 (sDKK3) in predicting Early Neurological Deterioration (END) and in-hospital adverse outcomes in acute ischemic stroke (AIS) patients. Methods AIS patients (n = 200) were included and assessed by the National Institutes of Health Stroke Rating Scale. Serum Dkk3 levels were assessed by ELISA. END was defined as an increase of ≥ 4 points in NIHSS score within 72h. The biological threshold of sDKK3 level and END occurrence were predicted based on X-tile software. Primary outcomes were END and all-cause death, and the secondary outcome was ICU admission during hospitalization. The logistic regression model and Cox risk regression model were applied to evaluate the relationship between DKK3 level and END incidence, all-cause in-hospital mortality, and in-hospital adverse outcomes (ICU admission). Results During hospitalization, the incidence of END in patients with AIS was 13.0 %, and the mortality rate within 7 days after END was 11.54 % (3/26). In patients below the serum DKK3 cutoff (93.0 pg/mL), the incidence of END was 43.5 % (20/48). Patients with lower sDKK3 levels were associated with a 1.188-fold increased risk of developing END (OR = 1.188, 95 % CI 1.055‒1.369, p < 0.0001). However, there was no significant association with admission to the ICU. sDKK3 below the threshold (93.0 pg/mL) was a risk factor for death. Conclusion Predictive threshold levels of serum DKK3 based on X-tile software may be a potential predictive biomarker of in-hospital END in patients with AIS, and low levels of DKK3 are independently associated with increased in-hospital mortality.

Are we ready to stratify BI-RADS 4 lesions observed on magnetic resonance imaging? A real-world noninferiority/equivalence analysis / Estamos prontos para estratificar lesões BI-RADS 4 na ressonância magnética? Uma análise de não inferioridade/equivalência do mundo real

Abstract Objective: To demonstrate that positive predictive values (PPVs) for suspicious (category 4) magnetic resonance imaging (MRI) findings that have been stratified are equivalent to those stipulated in the American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) for mammography and ultrasound. Materials and Methods: This retrospective analysis of electronic medical records generated between January 4, 2016 and December 29, 2021 provided 365 patients in which 419 suspicious (BI-RADS category 4) findings were subcategorized as BI-RADS 4A, 4B or 4C. Malignant and nonmalignant outcomes were determined by pathologic analyses, follow-up, or both. For each subcategory, the level 2 PPV (PPV2) was calculated and tested for equivalence/noninferiority against the established benchmarks. Results: Of the 419 findings evaluated, 168 (40.1%) were categorized as malignant and 251 (59.9%) were categorized as nonmalignant. The PPV2 for subcategory 4A was 14.2% (95% CI: 9.3-20.4%), whereas it was 41.2% (95% CI: 32.8-49.9%) for subcategory 4B and 77.2% (95% CI: 68.4-84.5%) for subcategory 4C. Multivariate analysis showed a significantly different cancer yield for each subcategory (p < 0.001). Conclusion: We found that stratification of suspicious findings by MRI criteria is feasible, and malignancy probabilities for sub-categories 4B and 4C are equivalent to the values established for the other imaging methods in the BI-RADS. Nevertheless, low suspicion (4A) findings might show slightly higher malignancy rates.

Resumo Objetivo: Demonstrar que os valores preditivos positivos (VPPs) para lesões suspeitas (categoria 4) identificadas por ressonância magnética (RM) são equivalentes aos estipulados no ACR BI-RADS para mamografia e ultrassonografia. Materiais e Métodos: Análise retrospectiva de dados em prontuário eletrônico, entre 4 de janeiro de 2016 e 29 de dezembro de 2021, resultou em 365 pacientes elegíveis, com 419 lesões classificadas como BI-RADS 4A, 4B ou 4C. Desfechos malignos e não malignos foram determinados por estudo patológico e/ou acompanhamento. Realizamos o cálculo do VPP nível 2 (VPP2) para cada subcategoria e testamos para não inferioridade/equivalência em relação aos valores de referência. Resultados: Dos 419 achados, 168 (40,1%) foram malignos e 251 (59,9%), não malignos. O VPP2 para subcategoria 4A foi 14,2% (IC 95%: 9,3-20,4%), para 4B foi 41,2% (IC 95%:, 32,8-49,9%) e para 4C foi 77,2% (IC 95%: 68,4-84,5%). Análise multivariada demonstrou diferenças estatisticamente significantes entre as subcategorias (p < 0,001). Conclusão: A estratificação de achados suspeitos por RM é factível, sendo que a probabilidade de malignidade das subcategorias 4B e 4C é equivalente à estabelecida para outros métodos de imagem pelo BI-RADS. Contudo, lesões de baixa suspeição (4A) podem apresentar taxas mais altas de malignidade.

Alergia a la leche de vaca: ¿se pueden evitar las pruebas de provocación oral? Un análisis probabilístico basado en datos clínicos / Cow's milk allergy: Can oral food challenges be avoided? A probabilistic analysis based on clinical data

Introducción. La prueba de provocación oral (PPO) para el diagnóstico de alergia a las proteínas de la leche de la vaca (APLV) presenta riesgos y requiere de recursos. Nuestro objetivo fue evaluar condiciones y pruebas complementarias para identificar una alta probabilidad de APLV. Población y métodos. Análisis secundario sobre estudio de pacientes atendidos en una unidad de alergia entre 2015 y 2018. Se determinaron las probabilidades prepruebas asociadas a los síntomas y sus combinaciones, y las probabilidades pospruebas luego de realizadas pruebas cutáneas y determinación de inmunoglobulina E (IgE) sérica. Resultados. Se evaluó la información de 239 pacientes. Se observaron probabilidades mayores al 95 % en pacientes con angioedema y combinación de urticaria y vómitos. Usando puntos de corte propuestos por Calvani et al., la combinación de vómitos con rinitis, sin angioedema, también superó el 95 %. Conclusión. Se ofrece una metodología para identificar pacientes en los que puede diagnosticarse APLV sin realización de PPO.

Introduction. The oral food challenge (OFC) for the diagnosis of cow's milk protein allergy (CMPA) poses risks and requires resources. Our objective was to assess conditions and complementary tests used to identify a high probability of CMPA. Population and methods. Secondary analysis of a study of patients seen at a unit of allergy between 2015 and 2018. Pre-testing probabilities associated with symptoms and their combinations and post-testing probabilities after skin prick testing and serum immunoglobulin E (IgE) levels were determined. Results. The data from 239 patients were assessed. A probability greater than 95% was observed for angioedema and a combination of urticaria and vomiting. Based on the cut-off points proposed by Calvani et al., the combination of vomiting with rhinitis, without angioedema, also exceeded 95%. Conclusion. A methodology is provided to identify patients in whom CMPA may be diagnosed without an OFC.

Instrumentos para la evaluación del riesgo de lesiones por presión en adultos en estado crítico: scoping review / Risk assessment instruments for pressure ulcer in adults in critical situation: a scoping review / Instrumentos para a avaliação do risco de lesões por pressão para adultos em situação crítica: scoping review*

Objetivo: mapear los instrumentos para la evaluación del riesgo de lesiones por presión en adultos en situación crítica en una unidad de terapia intensiva; identificar los indicadores de desempeño de los instrumentos y la apreciación de los usuarios con respecto al uso/limitaciones de los instrumentos. Método: scoping review. Para redactar el estudio se utilizó la extensión Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. La investigación se realizó mediante la herramienta de búsqueda EBSCOhost en 8 bases de datos, resultando 1846 estudios, de los cuales 22 conforman la muestra. Resultados: se identificaron dos grandes grupos de instrumentos: los generalistas [Braden, Braden (ALB), Emina, Norton-MI, RAPS y Waterlow]; y los específicos (CALCULATE, Cubbin & Jackson, EVARUCI, RAPS-ICU, Song & Choi, Suriaidi y Sanada y el índice COMHON). En cuanto al valor predictivo, EVARUCI y CALCULATE mostraron los mejores resultados de indicadores de desempeño. En cuanto a las apreciaciones/limitaciones señaladas por los usuarios, destaca la escala CALCULATE, seguida de la EVARUCI y la RAPS-ICU, aunque aún necesitan ajustes futuros. Conclusión: el mapeo mostró que las evidencias son suficientes para indicar uno o más instrumentos para la evaluación del riesgo de lesiones por presión en adultos críticos en una unidad de cuidados intensivos.

Objective: to map the instruments for risk assessment of pressure ulcers in adults in critical situation in intensive care units; identify performance indicators of the instrument, and the appreciation of users regarding the instruments' use/limitations. Method: a scoping review. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews in the writing of the study. We carried out the searches in the EBSCOhost search tool for 8 databases, resulting in 1846 studies, of which 22 studies compose the sample. Results: we identified two big instrument groups: generalist [Braden, Braden (ALB), Emina, Norton-MI, RAPS, and Waterlow]; and specific (CALCULATE, Cubbin & Jackson, EVARUCI, RAPS-ICU, Song & Choi, Suriaidi and Sanada, and COMHON index). Regarding the predictive value, EVARUCI and CALCULATE presented better results for performance indicators. Concerning appreciation/limitations indicated by users, we highlight the CALCULATE scale, followed by EVARUCI and RAPS-ICU, although they still need future adjustments. Conclusion: the mapping of the literature showed that the evidence is sufficient to indicate one or more instruments for the risk assessment of pressure ulcers for adults in critical situation in intensive care units.

Objetivo: mapear os instrumentos para avaliação do risco de lesões por pressão nos adultos em situação crítica em unidade de cuidados intensivos; identificar os indicadores de desempenho dos instrumentos e a apreciação dos utilizadores quanto ao uso/às limitações dos instrumentos. Método: scoping review. O Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews foi utilizado para a redação do estudo. A pesquisa foi realizada na ferramenta de busca EBSCOhost em oito bases de dados, resultando em 1846 estudos, dos quais 22 compõem a amostra. Resultados: identificaram-se dois grandes grupos de instrumentos: os genéricos [Braden, Braden (ALB), Emina, Norton-MI, RAPS e Waterlow]; e os específicos (CALCULATE, Cubbin & Jackson, EVARUCI, RAPS-ICU, Song & Choi, Suriaidi e Sanada e o índice de COMHON). Quanto ao valor preditivo, a EVARUCI e a CALCULATE apresentaram os melhores resultados de indicadores de desempenho. Em relação à apreciação/às limitações apontadas pelos utilizadores, destacam-se a escala CALCULATE, seguindo-se da EVARUCI e da RAPS-ICU, embora ainda necessitem de ajustes futuros. Conclusão: o mapeamento mostrou que as evidências são suficientes para indicar um ou mais instrumentos para avaliação do risco de lesões por pressão nos adultos em situação crítica em unidade de cuidados intensivos.

Procalcitonin and C-reactive protein: markers in the early diagnosis of anastomotic leak.

OBJECTIVE: To determine the efficacy of serum procalcitonin (PCT) and C-reactive protein (CRP) in the early diagnosis of anastomotic leak (AL) in patients undergoing colorectal surgery. METHOD: Diagnostic test in a tertiary care hospital. Patients who did not have preoperative measurements of PCT and CRP were excluded. Those with postoperative infection not related to AL were eliminated. The diagnostic efficacy measures were sensitivity (Sn), specificity (Sp), positive (PPV) and negative (NPV) predictive values, positive (LR+) and negative (LR-) likelihood ratios, and area under the receiver operating characteristic curve (AUROC). RESULTS: Thirty-nine patients were analyzed; six had AL (15.4%). PCT and CRP increased on the second postoperative day, only in patients with AL. The cut-off points at the second postoperative day were 1.55 ng/mL for PCT and 11.25 mg/L for CRP. The most efficacious test was PCR at second postoperative day (AUROC: 1.00; Sn: 100%; Sp: 96.7%; PPV: 85.7%; NPV: 100%; LR+: 33.0). CONCLUSIONS: CRP at second postoperative day was the most effective test in the early diagnosis of AL in patients undergoing colorectal surgery, with a cut-off point lower than that reported in the international literature.

OBJETIVO: Determinar la eficacia de la procalcitonina (PCT) y la proteína C reactiva (PCR) séricas en el diagnóstico de fuga anastomótica (FA) en los pacientes sometidos a cirugía colorrectal. MÉTODO: Prueba diagnóstica en un hospital de tercer nivel. Se excluyeron los pacientes que no tuvieron mediciones preoperatorias de PCT y PCR. Se eliminaron los que cursaron con infección posoperatoria no relacionada con FA. Las medidas de eficacia diagnóstica fueron sensibilidad (S), especificidad (E), valores predictivos positivo (VPP) y negativo (VPN), razones de verosimilitud positiva (RV+) y negativa (RV−), y área bajo la curva característica operativa del receptor (AUROC). RESULTADOS: Se analizaron 39 pacientes, de los cuales 6 (15.4%) tuvieron FA. La PCT y la PCR aumentaron al segundo día posoperatorio solo en los pacientes con FA. Los puntos de corte al día 2 fueron 1.55 ng/ml para PCT y 11.25 mg/l para PCR. La prueba más eficaz fue la PCR al día 2 (AUROC: 1.00; S: 100%; E: 96.7%; VPP: 85.7%; VPN: 100%; RV+: 33.0). CONCLUSIONES: La PCR en el segundo día posoperatorio fue la prueba más eficaz en el diagnóstico temprano de FA en los pacientes sometidos a cirugía colorrectal, con un punto de corte inferior a lo reportado en la literatura internacional.

Predictive validity of the EVARUCI scale to evaluate risk for pressure injury in critical care patients.

OBJECTIVE: To compare the predictive capacity of the current risk assessment scale for pressure ulcers in intensive care (EVARUCI), translated into Brazilian Portuguese, using the Braden scale. METHOD: This cross-sectional study collected prospective data from adult patients in three intensive care units. The receiver operating characteristic (ROC) and precision-recall curve (PR curve) were used to analyse the predictive capacity for pressure injury (PI) using both predictive values and odds ratios (ORs). RESULTS: The incidence of PIs in the study sample of 324 patients was 14.2%. The area under the ROC curve was 0.807 for EVARUCI and 0.798 for the Braden scale. At a cutoff point of 10 on the EVARUCI scale, sensitivity was 69.6%; specificity 78.4%; positive predictive value 34.8%; and OR 8.3. At a cutoff point of 11 on the Braden scale, sensitivity was 76.1%; specificity 75.9%; positive predictive value 34.3%; and OR 10. The area under the PR curve was 0.396 for the EVARUCI scale and 0.348 for the Braden scale, reflecting a smaller area for both. The F1 score value was 0.476 with 37.5% precision and 65.2% recall for the EVARUCI scale, and 0.473 with 34.3% precision and 76.1% recall for the Braden scale. CONCLUSION: The EVARUCI scale predictive capacity was similar to that of the Braden scale. However, the precision of both scales was low for the accurate prediction of patients at risk of developing PIs.

Optimizing strategies to identify high risk of developing type 2 diabetes.

Introduction: The success of diabetes prevention based on early treatment depends on high-quality screening. This study compared the diagnostic properties of currently recommended screening strategies against alternative score-based rules to identify those at high risk of developing diabetes. Methods: The study used data from ELSA-Brasil, a contemporary cohort followed up for a mean (standard deviation) of 7.4 (0.54) years, to develop risk functions with logistic regression to predict incident diabetes based on socioeconomic, lifestyle, clinical, and laboratory variables. We compared the predictive capacity of these functions against traditional pre-diabetes cutoffs of fasting plasma glucose (FPG), 2-h plasma glucose (2hPG), and glycated hemoglobin (HbA1c) alone or combined with recommended screening questionnaires. Results: Presenting FPG > 100 mg/dl predicted 76.6% of future cases of diabetes in the cohort at the cost of labeling 40.6% of the sample as high risk. If FPG testing was performed only in those with a positive American Diabetes Association (ADA) questionnaire, labeling was reduced to 12.2%, but only 33% of future cases were identified. Scores using continuously expressed clinical and laboratory variables produced a better balance between detecting more cases and labeling fewer false positives. They consistently outperformed strategies based on categorical cutoffs. For example, a score composed of both clinical and laboratory data, calibrated to detect a risk of future diabetes ≥20%, predicted 54% of future diabetes cases, labeled only 15.3% as high risk, and, compared to the FPG ≥ 100 mg/dl strategy, nearly doubled the probability of future diabetes among screen positives. Discussion: Currently recommended screening strategies are inferior to alternatives based on continuous clinical and laboratory variables.

Generación de un test predictivo para el diagnóstico de laetiología de la hemorragia digestiva alta variceal

Nuestro objetivo fue desarrollar un test diagnóstico para predecir la etiología de la Hemorragia Digestiva Alta Variceal (HDAV). Realizamos un estudio de cohorte retrospectivo. Se revisaron historias clínicas de pacientes mayores de 18 años con Hemorragia Digestiva Alta (HDA) que acudieron al servicio de emergencia del Hospital Cayetano Heredia (HCH) de Lima-Perú entre el 2019 a 2022, se recolectaron datos demográficos, de laboratorio y clínicos; posteriormente, se identificaron variables predictivas de HDAV mediante una regresión logística múltiple. A cada variable con capacidad predictiva se les asignó un puntaje con un punto de corte y sirvió para construir una escala predictiva de HDAV. Se incluyeron 197 historias clínicas de pacientes con HDA, de los cuales 127 (64%) tuvieron sangrado de causa no variceal, y, 70 (36%), variceal. Se identificaron 4 factores predictivos independientes: hematemesis (vómito rojo) (OR: 4,192, IC 95%: 1,586-11,082), recuento de plaquetas (OR: 3,786, IC 95%: 1,324-10,826), antecedente de HDA (OR: 2,634, IC 95%: 1,017-6,820), signos de enfermedad hepática crónica (OR: 11,244, IC 95%: 3,067-35,047), con los que se construyó una escala predictiva, con un punto de corte >7 y ≤7; que mostró una sensibilidad, especificidad, valor predictivo positivo, valor predictivo negativo, cociente de probabilidad positivo, y, negativo de 58,6%, 90,6%, 77,4%, 79,9%, 6,20, y 0,46 respectivamente. En conclusión, la escala predictiva con un punto de corte >7 es útil para predecir la presencia de la HDAV en pacientes que acuden a la emergencia por HDA.

Our objective was to develop a diagnostic test to predict the etiology of Variceal Upper Gastrointestinal Bleeding (VUGIB). We conducted a retrospective cohort study. Medical records of patients over 18 years of age with Upper Gastrointestinal Bleeding (UGIB) who attended the emergency service of Hospital Cayetano Heredia (HCH) in Lima-Peru between 2019 and 2022 were reviewed; demographic, laboratory and clinical data were collected. Subsequently, predictive variables of variceal upper gastrointestinal bleeding (VUGIB) were identified using multiple logistic regression. Each variable with predictive capacity was assigned a score with a cut-off point and served to build a predictive scale for VUGIB. 197 medical records of patients with UGIB were included, of which 127 (64%) had non-variceal bleeding, and 70 (36%), variceal. Four independent predictors were identified: hematemesis (red vomit) (OR: 4,192, 95% CI: 1.586-11.082), platelet count (OR: 3.786, 95% CI: 1.324-10.826), history of UGIB (OR: 2.634, 95% CI: 1.017-6.820), signs of chronic liver disease (OR: 11.244, 95% CI: 3.067-35.047), with which a predictive scale was constructed, with a cut-off point >7 and ≤7; which showed a sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative of 58.6%, 90.6%, 77.4%, 79.9%, 6.20, and 0.46 respectively. In conclusion, the predictive scale with a cut-off point >7 is useful for predicting the presence of VUGIB in patients who attend the emergency room for UGIB.

Effects of changing reference values on the interpretation of spirometry for rubber workers.

Introduction: The National Health and Nutrition Assessment Survey (NHANES) is being adopted for interpreting spirometry in occupational examinations. Rubber workers have an elevated risk of respiratory health issues due to industrial exposure, and changes in the equations would affect spirometry monitoring programs. Objective: To determine the differences in the use of the Knudson and NHANES III equations in nonsmoking workers in the rubber industry. Method: A cross-sectional study was conducted with 75 nonsmoking workers with occupational exposure to rubber for at least two years. The factory had engineered protection controls and provided respiratory protection to the workers. Spirometry was conducted according to Spirometry Testing in Occupational Health Programs and Standardization of Spirometry: American Thoracic Society/European Respiratory Society. Result: Spirometric prediction differences were present in the restrictive pattern assessment based on forced vital capacity (FVC), in which three individuals (4%) classified as normal according to Knudson presented restrictive disease according to NHANES III; only in the record of one participant was there restrictive disease using both equations. There was an 8% discrepancy for small airway obstruction in which six workers classified as normal using NHANES III were classified as diseased (FEF 25-75 <50%) using the Knudson equation. Conclusion: In the respiratory examination of workers exposed to rubber, the NHANES III equation is better able to detect restrictive diseases than is the Knudson equation; however, the Knudson equation is more sensitive to obstructive patterns.

Cow's milk allergy: Can oral food challenges be avoided? A probabilistic analysis based on clinical data. / Alergia a la leche de vaca: ¿se pueden evitar las pruebas de provocación oral? Un análisis probabilístico basado en datos clínicos.

Introduction. The oral food challenge (OFC) for the diagnosis of cow's milk protein allergy (CMPA) poses risks and requires resources. Our objective was to assess conditions and complementary tests used to identify a high probability of CMPA. Population and methods. Secondary analysis of a study of patients seen at a unit of allergy between 2015 and 2018. Pre-testing probabilities associated with symptoms and their combinations and post-testing probabilities after skin prick testing and serum immunoglobulin E (IgE) levels were determined. Results. The data from 239 patients were assessed. A probability greater than 95% was observed for angioedema and a combination of urticaria and vomiting. Based on the cut-off points proposed by Calvani et al., the combination of vomiting with rhinitis, without angioedema, also exceeded 95%. Conclusion. A methodology is provided to identify patients in whom CMPA may be diagnosed without an OFC.

Introducción. La prueba de provocación oral (PPO) para el diagnóstico de alergia a las proteínas de la leche de la vaca (APLV) presenta riesgos y requiere de recursos. Nuestro objetivo fue evaluar condiciones y pruebas complementarias para identificar una alta probabilidad de APLV. Población y métodos. Análisis secundario sobre estudio de pacientes atendidos en una unidad de alergia entre 2015 y 2018. Se determinaron las probabilidades prepruebas asociadas a los síntomas y sus combinaciones, y las probabilidades pospruebas luego de realizadas pruebas cutáneas y determinación de inmunoglobulina E (IgE) sérica. Resultados. Se evaluó la información de 239 pacientes. Se observaron probabilidades mayores al 95 % en pacientes con angioedema y combinación de urticaria y vómitos. Usando puntos de corte propuestos por Calvani et al., la combinación de vómitos con rinitis, sin angioedema, también superó el 95 %. Conclusión. Se ofrece una metodología para identificar pacientes en los que puede diagnosticarse APLV sin realización de PPO.

A prospective validation and comparison of three multivariate models for prediction of difficult intubation in adult patients

Abstract Purpose Several bedside clinical tests have been proposed to predict difficult tracheal intubation. Unfortunately, when used alone, these tests show less than ideal prediction performance. Some multivariate tests have been proposed considering that the combination of some criteria could lead to better prediction performance. The goal of our research was to compare three previously described multivariate models in a group of adult patients undergoing general anesthesia. Methods This study included 220 patients scheduled for elective surgery under general anesthesia. A standardized airway evaluation which included modified Mallampati class (MM), thyromental distance (TMD), mouth opening distance (MOD), head and neck movement (HNM), and jaw protrusion capacity was performed before anesthesia. Multivariate models described by El-Ganzouri et al., Naguib et al., and Langeron et al. were calculated using the airway data. After anesthesia induction, an anesthesiologist performed the laryngoscopic classification and tracheal intubation. The sensitivity, specificity, and receiver operating characteristic (ROC) curves of the models were calculated. Results The overall incidence of difficult laryngoscopic view (DLV) was 12.7%. The area under curve (AUC) for the Langeron, Naguib, and El-Ganzouri models were 0.834, 0.805, and 0.752, respectively, (Langeron > El-Ganzouri, p= 0.004; Langeron = Naguib, p= 0.278; Naguib = El-Ganzouri, p= 0.101). The sensitivities were 85.7%, 67.9%, and 35.7% for the Langeron, Naguib, and El-Ganzouri models, respectively. Conclusion The Langeron model had higher overall prediction performance than that of the El-Ganzouri model. Additionally, the Langeron score had higher sensitivity than the Naguib and El-Ganzouri scores, and therefore yielded a lower incidence of false negatives.