The error of estimated GFR in predialysis care.

The error of estimated glomerular filtration rate (eGFR) and its consequences in predialysis are unknown. In this prospective multicentre study, 315 predialysis patients underwent measured GFR (mGFR) by the clearance of iohexol and eGFR by 52 formulas. Agreement between eGFR and mGFR was evaluated by concordance correlation coefficient (CCC), total deviation index (TDI) and coverage probability (CP). In a sub-analysis we assessed the impact of eGFR error on decision-making as (i) initiating dialysis, (ii) preparation for renal replacement therapy (RRT) and (iii) continuing clinical follow-up. For this sub-analysis, patients who started RRT due to clinical indications (uremia, fluid overload, etc.) were excluded. eGFR had scarce precision and accuracy in reflecting mGFR (average CCC 0.6, TDI 70% and cp 22%) both in creatinine- and cystatin-based formulas. Variations -larger than 10 ml/min- between mGFR and eGFR were frequent. The error of formulas would have suggested (a) premature preparation for RTT in 14% of stable patients evaluated by mGFR; (b) to continue clinical follow-up in 59% of subjects with indication for RTT preparation due to low GFRm and (c) to delay dialysis in all asymptomatic patients (n = 6) in whom RRT was indicated based on very low mGFR. The error of formulas in predialysis was frequent and large and may have consequences in clinical care.

The Ratio of Monocytes to HDL-Cholesterol Is Associated with Cardiovascular Risk and Insulin Resistance in Patients with Rheumatoid Arthritis.

The monocytes to high-density lipoprotein (HDL)-cholesterol ratio (MHR) indicates inflammation based on the anti-inflammatory properties of HDL-cholesterol as well as the pro-inflammatory effect of monocytes. Several studies have investigated MHR in various disorders, specifically in cardiovascular diseases. Consequently, MHR has been significantly associated with cardiovascular and all-cause mortality in the general population, regardless of established risk factors. However, its role in the augmented risk of cardiovascular disease found in rheumatoid arthritis (RA) has not been studied to date. This is a cross-sectional study that encompassed 430 patients with RA and 208 controls matched by sex and age. Complete blood cell count and complete lipid profile were evaluated. Multivariable analysis was made to analyze the relationship between MHR and RA disease and features subclinical carotid atherosclerosis, and traditional CV factors including insulin resistance and beta cell function indices. MHR values did not differ between controls and patients after multivariable adjustment (12 ± 6 vs. 11 ± 6, p = 0.18). No relationship between this ratio and the characteristics of the disease was found excluding ESR, which showed a significant and positive association with MHR after adjustment for covariates. MHR significantly correlated with Systematic Coronary Risk Evaluation-2 (SCORE2) cardiovascular risk algorithm, and insulin resistance and beta cell function parameters after adjustment. In conclusion, MHR does not differ between patients with RA and controls. The relationship of this biomarker with disease-related data is poor. However, MHR is highly and positively related to cardiovascular risk and insulin resistance in RA.

Prevalence and clinical impact of alcohol withdrawal syndrome in alcohol-associated hepatitis and the potential role of prophylaxis: a multinational, retrospective cohort study.

Background: The prevalence and impact of alcohol withdrawal syndrome (AWS) in patients with alcohol-associated hepatitis (AH) are unknown. In this study, we aimed to investigate the prevalence, predictors, management, and clinical impact of AWS in patients hospitalized with AH. Methods: A multinational, retrospective cohort study enrolling patients hospitalized with AH at 5 medical centres in Spain and in the USA was performed between January 1st, 2016 to January 31st, 2021. Data were retrospectively retrieved from electronic health records. Diagnosis of AWS was based on clinical criteria and use of sedatives to control AWS symptoms. The primary outcome was mortality. Multivariable models controlling for demographic variables and disease severity were performed to determine predictors of AWS (adjusted odds ratio [OR]) and the impact of AWS condition and management on clinical outcomes (adjusted hazard ratio [HR]). Findings: In total, 432 patients were included. The median MELD score at admission was 21.9 (18.3-27.3). The overall prevalence of AWS was 32%. Lower platelet levels (OR = 1.61, 95% CI 1.05-2.48) and previous history of AWS (OR = 2.09, 95% CI 1.31-3.33) were associated with a higher rate of incident AWS, whereas the use of prophylaxis decreased the risk (OR = 0.58, 95% CI 0.36-0.93). The use of intravenous benzodiazepines (HR = 2.18, 95% CI 1.02-4.64) and phenobarbital (HR = 2.99, 95% CI 1.07-8.37) for AWS treatment were independently associated with a higher mortality. The development of AWS increased the rate of infections (OR = 2.24, 95% CI 1.44-3.49), the need for mechanical ventilation (OR = 2.49, 95% CI 1.38-4.49), and ICU admission (OR = 1.96, 95% CI 1.19-3.23). Finally, AWS was associated with higher 28-day (HR = 2.31, 95% CI 1.40-3.82), 90-day (HR = 1.78, 95% CI 1.18-2.69), and 180-day mortality (HR = 1.54, 95% CI 1.06-2.24). Interpretation: AWS commonly occurs in patients hospitalized with AH and complicates the hospitalization course. Routine prophylaxis is associated with a lower prevalence of AWS. Prospective studies should determine diagnostic criteria and prophylaxis regimens for AWS management in patients with AH. Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Inflammation on the Waiting List Is a Risk Factor for New-Onset Prediabetes and Post-Transplant Diabetes Mellitus: A Prospective Study.

INTRODUCTION: Inflammation is a risk factor for diabetes in the general population. The role of inflammation in prediabetes or post-transplant diabetes mellitus (PTDM) is not clear. We evaluated the association between inflammatory markers in patients on the waiting list for renal transplantation and the onset of prediabetes and PTDM 12 months after transplantation. METHODS: This is a post hoc analysis of a prospective study that included nondiabetic patients on the waiting list for kidney transplantation who underwent an oral glucose tolerance test (OGTT) and were followed up to 12 months after transplantation. At this time, those patients without PTDM underwent another OGTT. At pre-transplantation, five cytokines: TNFα, IL6, IL1ß, CRP, MCP1 were determined. The association between inflammation and prediabetes/PTDM was evaluated using multiple regression models. RESULTS: 110 patients on the waiting list were enrolled: 74 had normal glucose metabolism and 36 had prediabetes or occult diabetes. At 12 months, 53 patients had normal glucose metabolism, 25 prediabetes, and 32 PTDM. In multiple regression analysis, pre-transplant inflammation was not a risk factor for prediabetes or PTDM. This was attributed to the high interrelation between obesity, prediabetes, and inflammation: about 75% of the cases had these conditions. In a sub-analysis, we analyzed only patients without prediabetes and occult diabetes on the waiting list and found that TNFα levels and BMI at pre-transplantation were independently associated with the onset of prediabetes or PTDM 1 year after transplantation. CONCLUSIONS: Pre-transplant inflammation and BMI are risk factors for prediabetes and PTDM in patients without glucose metabolism alterations.

Exercise and Prediabetes After Renal Transplantation (EXPRED-I): A Prospective Study.

BACKGROUND: Post-transplant diabetes mellitus (PTDM) beyond 12 months (late PTDM) is a severe complication after renal transplantation. Late PTDM develops mostly in subjects with prediabetes. Although exercise may have a potential role in preventing late PTDM, there are no previous data on the effect of exercise in patients with prediabetes. MATERIAL AND METHODS: The design was a 12-month exploratory study to test the capacity of exercise in reverting prediabetes in order to prevent late-PTDM. The outcome was the reversibility of prediabetes, assessed every 3 months with oral glucose tolerance tests (OGTT). The protocol included an incremental plan of aerobic and/or strength training as well as an active plan for promoting adherence (telephone calls, digital technology, and visits). A priori, a sample size cannot be calculated which makes this an exploratory analysis. Based on previous studies, the spontaneous reversibility of prediabetes was 30% and the reversibility induced by exercise will account for another 30%, a total reversibility of 60% (p value < 0.05, assuming a potency of 85%). Ad interim analysis was performed during follow-up to test the certainty of this sample calculation. Patients beyond 12 months after renal transplantation with prediabetes were included. RESULTS: The study was interrupted early due to efficacy after the evaluation of the follow-up of 27 patients. At the end of follow-up, 16 (60%) patients reverted to normal glucose levels at fasting (from 102.13 mg/dL ± 11 to 86.75 ± 6.9, p = 0.006) and at 120 min after the OGTTs (154.44 mg/dL ± 30 to 113.0 ± 13.1, p = 0.002) and 11 patients had persistent prediabetes (40%). Also, insulin sensitivity improved with the reversibility of prediabetes, compared to those with persistent prediabetes: 0.09 [0.08-0.11] versus 0.04 [0.01-0.07], p = 0.001 (Stumvoll index). Most needed at least one increment in the prescription of exercise and compliance. Finally, measures aimed at the improvement of compliance were successful in 22 (80%) patients. CONCLUSION: Exercise training was effective to improve glucose metabolism in renal transplant patients with prediabetes. Exercise prescription must be conducted considering both the clinical characteristics of the patients and pre-defined strategy to promote adherence. The trial registration number of the study was NCT04489043.

High Effectiveness of Midazolam and Lidocaine in the Treatment of Acute Neonatal Seizures.

PURPOSE: To assess the clinical effectiveness of treating acute seizures with midazolam and lidocaine infusion. METHODS: This single-center historical cohort study included 39 term neonates with electrographic seizures who underwent treatment with midazolam (1st line) and lidocaine (2nd line). Therapeutic response was measured using continuous video-EEG monitoring. The EEG measurements included total seizure burden (minutes), maximum ictal fraction (minutes/hour), and EEG-background (normal/slightly abnormal vs. abnormal). Treatment response was considered good (seizure control with midazolam infusion), intermediate (need to add lidocaine to the control), or no response. Using clinical assessments supplemented by BSID-III and/or ASQ-3 at 2 to 9 years old age, neurodevelopment was classified as normal, borderline, or abnormal. RESULTS: A good therapeutic response was obtained in 24 neonates, an intermediate response in 15, and no response in any of the neonates. Babies with good response showed lower values in maximum ictal fraction compared with those with intermediate response (95% CI: 5.85-8.64 vs. 9.14-19.14, P = 0.002). Neurodevelopment was considered normal in 24 children, borderline in five, and abnormal in other 10 children. Abnormal neurodevelopment was significantly associated with an abnormal EEG background, maximum ictal fraction >11 minutes, and total seizure burden >25 minutes (odds ratio 95% CI: 4.74-1708.52, P = 0.003; 1.72-200, P = 0.016; 1.72-142.86, P = 0.026, respectively) but not with the therapeutic response. Serious adverse effects were not recorded. CONCLUSIONS: This retrospective study suggests that the midazolam/lidocaine association could potentially be efficacious in decreasing seizure burden in term neonates with acute seizures. These results would justify testing the midazolam/lidocaine combination as a first-line treatment for neonatal seizures in future clinical trials.

Recomendaciones de «no hacer» en cuidados intensivos pediátricos en España: selección por método Delphi / Paediatric intensive care ‘do not do’ recommendations in Spain: Selection by Delphi method

Introducción: La asistencia sanitaria no está exenta de prácticas diagnósticas y terapéuticas poco efectivas, inseguras o ineficientes. Como reacción han sido propuestas recomendaciones de «no hacer» por diferentes sociedades científicas y autoridades sanitarias. Nuestro objetivo fue seleccionar y consensuar un grupo de recomendaciones de «no hacer» (RNH) en cuidados intensivos pediátricos en España. Material y método: Esta investigación se desarrolló en dos fases: primera, recopilación de posibles RNH; segunda, selección por método Delphi de las más importantes según prevalencia de la práctica a modificar, gravedad de sus potenciales riesgos, y facilidad con la que podría ser modificada. Tanto las propuestas como las evaluaciones fueron realizadas por miembros de grupos de trabajo de la Sociedad Española de Cuidados Intensivos Pediátricos (SECIP) coordinados por correo electrónico. El listado inicial de RNH fue reduciéndose en base al coeficiente de variación (<80%) de sus evaluaciones. Resultados: Fueron propuestas 182 RNH por 30 intensivistas. Los 14 evaluadores del Delphi lograron reducir el set inicial a 85 RNH y tras una segunda ronda se llegó a la selección final de 26 RNH. Las dimensiones de calidad más representadas en nuestro set final son la efectividad clínica y la seguridad de pacientes. Conclusiones: Nuestro trabajo ha permitido seleccionar y consensuar una serie de recomendaciones para evitar prácticas inseguras, ineficientes o inefectivas en intensivos pediátricos en España, lo que podría ser útil para mejorar la calidad de nuestra actividad clínica. (AU)

Introduction: Health care is not free of ineffective, unsafe or inefficient diagnostic and therapeutic practices. To address this, different scientific societies and health authorities have proposed ‘do not do’ recommendations (DNDRs). Our goal was the selection by consensus of a set of DNDRs for paediatric intensive care in Spain. Material and method: The research was carried out in two phases: first, gathering potential DNDRs; second, selecting the most important ones, using the Delphi method, based on the prevalence of the practice to be modified, the severity of its potential risks and the ease with which it could be modified. Proposals and evaluations were both made by members of working groups of the Sociedad Española de Cuidados Intensivos Pediátricos (SECIP, Spanish Society of Paediatric Intensive Care), coordinated by email. The initial set of DNDRs was reduced based on the coefficient of variation (<80%) of the corresponding evaluations. Results: A total of 182 DNDRs were proposed by 30 intensivists. The 14 Delphi evaluators managed to pare down the initial set to 85 DNDRs and, after a second round, to the final set of 26 DNDRs. The care quality dimensions most represented in the final set are clinical effectiveness and patient safety. Conclusions: This study allowed the selection by consensus of a series of recommendations to avoid unsafe, inefficient or ineffective practices in paediatric intensive care in Spain, which could be useful for improving the quality of clinical care in our field. (AU)

Paediatric intensive care 'do not do' recommendations in Spain: Selection by Delphi method.

INTRODUCTION: Health care is not free of ineffective, unsafe or inefficient diagnostic and therapeutic practices. To address this, different scientific societies and health authorities have proposed 'do not do' recommendations (DNDRs). Our goal was the selection by consensus of a set of DNDRs for paediatric intensive care in Spain. MATERIAL AND METHOD: The research was carried out in 2 phases: first, gathering potential DNDRs; second, selecting the most important ones, using the Delphi method, based on the prevalence of the practice to be modified, the severity of its potential risks and the ease with which it could be modified. Proposals and evaluations were both made by members of working groups of the Sociedad Española de Cuidados Intensivos Pediátricos (SECIP, Spanish Society of Paediatric Intensive Care), coordinated by email. The initial set of DNDRs was reduced based on the coefficient of variation (<80%) of the corresponding evaluations. RESULTS: A total of 182 DNDRs were proposed by 30 intensivists. The 14 Delphi evaluators managed to pare down the initial set to 85 DNDRs and, after a second round, to the final set of 26 DNDRs. The care quality dimensions most represented in the final set are clinical effectiveness and patient safety. CONCLUSIONS: This study allowed the selection by consensus of a series of recommendations to avoid unsafe, inefficient or ineffective practices in paediatric intensive care in Spain, which could be useful for improving the quality of clinical care in our field.

Anti-TNF vs tocilizumab in refractory uveitic cystoid macular edema due to Behcet's disease. Multicenter study of 49 patients.

OBJECTIVE: To compare the efficacy of TNF inhibitors (adalimumab (ADA) and infliximab (IFX)) vs tocilizumab (TCZ) in patients with refractory cystoid macular edema (CME) due to Behçet's disease (BD). METHODS: Multicenter study of patients with BD-associated CME refractory to conventional and/or biological immunosuppressive drugs. From a cohort of 177 patients treated with anti-TNF and 14 patients treated with TCZ, we selected those with CME at baseline. We analyzed the evolution of macular thickness (main outcome), best-corrected visual acuity (BCVA) and intraocular inflammation (Tyndall and vitritis) from baseline up to 4 years in the 3 groups mentioned. RESULTS: 49 patients and 72 eyes with CME were included. ADA was used in 25 patients (40 eyes), IFX in 15 (21 eyes) and TCZ in 9 (11 eyes). No statistically significant baseline differences were observed between the 3 groups except for a lower basal BCVA in TCZ group and a higher basal degree of intraocular inflammation in ADA group. Most patients from all groups had received several conventional immunosuppressive drugs. In addition, most patients in the group of TCZ had also received anti-TNF agents. Biological therapy was used in monotherapy (n=8) or combined with conventional immunosuppressive drugs (n=41). Macular thickness progressively decreased in the 3 groups, with no signs of CME after 1 year of treatment. Similarly, BCVA improvement and inflammatory intraocular remission was achieved in all groups. CONCLUSION: Refractory CME associated with BD uveitis can be effectively treated either with ADA, IFX or TCZ. Furthermore, TCZ is effective in patients resistant to anti-TNF therapy.

The Effectiveness of a Single Dry Needling Session on Gait and Quality of Life in Multiple Sclerosis: A Double-Blind Randomized Sham-Controlled Pilot Trial.

INTRODUCTION: Gait disorders are a major cause of disability and reduced health-related quality of life in people with multiple sclerosis (pwMS). Dry needling (DN) has demonstrated positive results to improve gait parameters in patients with stroke. The main aim of this study was to evaluate the effect of a single session of DN in the gait performance of pwMS. METHODS: A double-blind parallel randomized sham-controlled pilot trial was conducted. Study participants received a single session of active DN or sham DN in the gastrocnemius medialis muscle. Pre-treatment and immediately post-treatment measurements were taken, as well as at one and four weeks after the intervention. Outcomes related to gait performance (Timed 25-Foot Walk), self-perceived walking capacity (Multiple Sclerosis Walking Scale), risk of falls (Timed Up and Go test), disability level (Expanded Disability Status Score) and quality of life (Multiple Sclerosis Quality of Life-54 questionnaire and Analogic Quality of Life scale) were evaluated. RESULTS: 18 patients who had multiple sclerosis participated in the study. The group who received active DN showed within-group significant statistical differences immediately after treatment for gait performance (p = 0.008) and risk of falls (p = 0.008), as well as for self-perceived walking capacity at one week (p = 0.017) and four weeks (p = 0.011) and quality of life at four weeks (p = 0.014). Regarding the comparison between groups, only significant results were obtained in the physical domain of the quality of life at four weeks (p = 0.014). CONCLUSIONS: DN seems to be a promising therapeutic tool for the treatment of gait disorders in pwMS. However, when results were compared with sham DN, no differences were found.

Effectiveness of 2 interventions for independent oral feeding in preterms.

INTRODUCTION: Oral feeding of preterm newborns (PTNB) is hampered by their immaturity and intercurrent diseases, which can prolong their hospital stay. The objective of this study was to assess the effectiveness of a program that combines tactile, kinesthetic and oral stimulation (T + K + OS) compared to another intervention based on exclusively oral stimulation (OS), in the time necessary to achieve independent feeding and hospital discharge. PATIENTS AND METHODS: A clinical study of 2 randomized groups (OS vs. T + K + OS) was carried out on 42 PTNB with gestational age between 27-32 weeks and birth weight > 900 g. The stimulation programs were carried out in sessions of 15 min, for 10 days. RESULTS: The PTNBs in the T + K + OS group achieved independent oral feeding earlier, compared to the OS group (24.9 ± 10.1 vs. 34.1 ± 15.6 days, P = .02). An analysis of covariance was performed, which confirmed that the birth weight and gestational age covariates had significant effects on time to reach suction feeding (birth weight: F[1, 38] = 5.79; P = .021; gestational age: F[1, 38] = 14.12; P = .001) and that once its effect was controlled, the intervention continued to have a significant effect (F[1, 38] = 6.07; P = .018). The T + K + OS group, compared to the OS group, achieved an earlier hospital discharge (39 ± 15 vs. 45 ± 18 days), although the differences were not significant (P = .21). CONCLUSIONS: Combined therapies that include T + K + OS are more effective than OS alone, in order to achieve independent oral feeding in PTNBs.

Eficacia de 2 intervenciones para la alimentación oral independiente en pretérminos / Effectiveness of 2 interventions for independent oral feeding in preterms

Introducción: La alimentación oral de los recién nacidos pretérmino (RNPT) está dificultada por su inmadurez y enfermedades intercurrentes, lo que puede prolongar su estancia hospitalaria. El objetivo de este estudio fue valorar la efectividad de un programa que combina la estimulación táctil, kinestésica y oral (ET+K+O) frente a otro de estimulación oral sola (EO), en el tiempo necesario para lograr la alimentación independiente y el alta hospitalaria. Pacientes y métodos: Estudio clínico de 2 grupos aleatorizados (EO vs. ET+K+O), realizado en 42 RNPT con una edad gestacional entre 27-32 semanas y un peso al nacimiento>900g. Los programas de estimulación fueron realizados en sesiones de 15min, durante 10 días. Resultados: Los RNPT del grupo de ET+K+O consiguieron antes la alimentación oral independiente, en comparación con el grupo de EO (24,9±10,1 vs. 34,1±15,6 días, p=0,02). Se realizó un análisis de covarianza, observando que las covariables PN y EG tuvieron efectos significativos en el tiempo hasta alcanzar la alimentación por succión (peso al nacimiento: F[1, 38]=5,79; p=0,021; edad gestacional: F[1, 38]=14,12; p=0,001) y que una vez controlado su efecto, la intervención seguía teniendo un efecto significativo (F[1, 38]=6,07; p=0,018). El grupo de ET+K+O, en comparación con el de EO, consiguió antes el alta hospitalaria (39±15 vs. 45±18 días), si bien la diferencia no fue significativa (p=0,21). Conclusiones: Las terapias combinadas que asocian ET+K+O son más eficaces que la EO sola, para lograr la alimentación oral independiente en los RNPT. (AU)

Introduction: Oral feeding of pre-term newborns (PTNB) is hampered by their immaturity and intercurrent diseases, which can prolong their hospital stay. The objective of this study was to assess the effectiveness of a program that combines tactile, kinesthetic and oral stimulation (T+K+OS) compared to another intervention based on exclusively oral stimulation (OS), in the time necessary to achieve independent feeding and hospital discharge. Patients and methods: A clinical study of 2 randomized groups (OS vs. T+K+OS) was carried out on 42 PTNB with gestational age between 27-32 weeks and birth weight>900g. The stimulation programs were carried out in sessions of 15min, for 10 days. Results: The PTNBs in the T+K+OS group achieved independent oral feeding earlier, compared to the OS group (24.9±10.1 vs. 34.1±15.6 days, P=.02). An analysis of covariance was performed, which confirmed that the birth weight and gestational age covariates had significant effects on time to reach suction feeding (birth weight: F[1, 38]=5.79; P=.021; gestational age: F[1, 38]=14.12; P=.001) and that once its effect was controlled, the intervention continued to have a significant effect (F[1, 38]=6.07; P=.018). The T+K+OS group, compared to the OS group, achieved an earlier hospital discharge (39±15 vs. 45±18 days), although the differences were not significant (P=.21). Conclusions: Combined therapies that include T+K+OS are more effective than OS alone, in order to achieve independent oral feeding in PTNBs. (AU)

Effectiveness and Safety of Attic Exposition-Antrum Exclusion versus Canal Wall-Up in Patients with Acquired Stage Ib and II Cholesteatoma Affecting the Attic and Tympanic Cavity.

This study aims to test the effectiveness and safety of exteriorization surgery comprising atticotomy and obliteration of the additus ad antrum, also referred to as attic exposition-antrum exclusion (AE-AE) surgery. This surgery combines otoendoscopy with surgical microscopy for the treatment of acquired pars flaccida cholesteatoma in stages Ib and II (according to the classification of the Japan Otological Society) present in the attic and the tympanic cavity. We reviewed a historical cohort of 65 patients. Of the total, 21 were treated with canal wall-up tympanomastoidectomy (CWU). Patients in whom the AE-AE technique was performed had residual and recurrence rates of 0% and 9.1%, respectively, compared with 28.6% and 9.5%, respectively, for those treated with CWU. In the AE-AE procedure, surgery is performed in one stage compared with the two stages in CWU, to address the risk of residual cholesteatoma. Auditory thresholds were higher in the CWU group compared with the AE-AE group in the pre-surgery (53 ± 16 vs. 44 ± 15 dB; p = 0.039) and post-surgery (52 ± 18 vs. 42 ± 16 dB; p = 0.042) evaluations but not in pre-post-surgery comparisons for either the AE-AE technique (p = 0.89) or the CWU technique (p = 0.96). We conclude that AE-AE is an effective and safe technique for the treatment of acquired stage Ib and II cholesteatoma present in the attic and tympanic cavities.

Moving average as a method of assessing risk of pressure injury using the COMHON index (Conscious level, Mobility, Hemodynamic, Oxygenation, Nutrition) for patients in intensive care units.

BACKGROUND: Moving average is the continuously updated arithmetic mean of the pressure injury (PI) risk score values measured with the COMHON Index (Conscious level, Mobility, Hemodynamics, Oxygenation, Nutrition). OBJECTIVE: The objective of this study was to validate the moving average as a method to measure the level of risk of PI. METHOD: This is a cohort study of adult patients admitted for a duration of more than 24 h in an intensive care unit (ICU) of a tertiary-level university hospital, between June 1, 2018, and December 31, 2019. The risk of PI was obtained with the COMHON Index, and its 3-day moving average was used to monitor the risk of PI. To assess the predictive ability of the moving average score, a receiver operating characteristic curve analysis was performed, obtaining the area under the curve, and the Youden Index to determine the optimal cut-off point of the PI risk moving average score using the COMHON Index. RESULTS: A total of 1335 patients (94.6% of admissions) were included, and 82 developed PI (cumulative incidence of 6.1%) in the 18 months of the study. The highest incidence of PI was in the sacrum (49%) followed by the heel (17.6%). The median age was 65 (54-73) years, and the median length of stay was 3.8 (1.9-9) days. The moving average score had an area under the receiver operating characteristic curve of 87% (95% confidence interval: 85%-89%), with a cut-off point of the moving average score ≥11, and the negative predictive value was 99.6%. CONCLUSIONS: The moving average score combined with a validated scale is a useful method to predict potential PI of patients admitted to the ICU. Its use is suggested for decision-making during the implementation of the care plan related to the prevention of PI in patients admitted to the ICU.

Estimated GFR Slope in Kidney Transplant Patients: When the Error Is Random.

BACKGROUND: The evaluation of renal function changes over time is crucial in day-to-day renal transplant care, and the slope of renal function is a major outcome in clinical trials. Little is known about the reliability of estimated glomerular filtration rate (eGFR) in reflecting real glomerular filtration rate (GFR) changes. METHODS: We analyzed the variability of eGFR slope by 63 equations in estimating measured GFR (mGFR) changes in 110 renal transplant patients. The agreement between eGFR and mGFR slopes was evaluated by the concordance correlation coefficient and the limits of agreement. Patients were grouped based on mGFR slope in rapid GFR loss: faster than -3 mL/min/y; stable renal function: -3 to +3 mL/min/y; and improvement in GFR: higher than +3 mL/min/y. RESULTS: Concordance correlation coefficient averaged 0.36 and limits of agreement ±10 mL/min/y, indicating very poor agreement between eGFR and mGFR slopes. The eGFR slope classified patients into the same group of mGFR slope only in 25% of the cases. In about two-thirds of patients, the eGFR slope was either markedly faster or slower than the mGFR slope. In half of these cases, the discrepancy between mGFR and eGFR slopes was ≥50%. CONCLUSIONS: Formulas are neither accurate nor precise in reflecting real GFR decline in renal transplant patients, making them unreliable for clinical practice and trials.

Patient-reported outcomes and digital literacy of patients treated in an oncology day hospital unit.

INTRODUCTION: Patient-reported outcomes (PROs) use, via a computer registry, allows patients to report their symptoms enabling the detection of early signs of progression of the disease. For such a record, the patient needs to show certain skills in new technologies use. The present study aimed to analyse the perception and degree of digital literacy of patients undergoing oncological treatment in an Oncology Day Hospital (ODH). METHODS: A cross-sectional descriptive study was performed, where the degree of literacy of patients attending antineoplastic treatment at the ODH was examined by means of an anonymous survey. RESULTS: A total of 122 patients have been included in the study. The proportion of subjects who use the electronic mail (TM) and the Internet on a daily basis was 45.1% and 70.5%, respectively, and up to 77.9% from the subjects considered that the use of digital 2.0 strategies could help improve communication between healthcare professional and patient.The TM was determined by the age, educational level and employment status of the individual. Furthermore, the age of the patients conditioned their perception of the usefulness of the web 2.0 tools (T2.0). CONCLUSION: This study allowed us to establish a target patient profile to conduct the efficient monitoring of cancer progression by PROs. The results have shown that approximately 60% of the patients in our population could be potential candidates to receive PROs-based health care. This approach enables earlier detection of symptoms and signs of progression and consequently, improves health outcomes for cancer patients.

Efficacy and safety of intermittent repeated levosimendan infusions in advanced heart failure patients: the LAICA study.

AIMS: The aim of the LAICA study was to evaluate the long-term effectiveness and safety of intermittent levosimendan infusion in patients with advanced heart failure (AdHF). METHODS AND RESULTS: This was a multicentre, randomized, double-blind, placebo-controlled clinical trial of intermittent levosimendan 0.1 µg/kg/min as a continuous 24-h intravenous infusion administered once monthly for 1 year in patients with AdHF. The primary endpoint [incidence of rehospitalization (admission to the emergency department or hospital ward for >12 h) for acute decompensated HF or clinical deterioration of the underlying HF] occurred in 23/70 (33%) of the levosimendan group (Group I) and 12/27 (44%) of the placebo group (Group II) (P = 0.286). The incidence of hospital readmissions for acute decompensated HF (Group I vs. Group II) at 1, 3, 6, and 12 months was 4.2% vs. 18.2% (P = 0.036); 12.8% vs. 33.3% (P = 0.02); 25.7% vs. 40.7% (P = 0.147); 32.8% vs. 44.4% (P = 0.28), respectively. In a secondary pre-specified time-to-event analysis no differences were observed in admission for acute decompensated HF between patients treated with levosimendan compared with placebo (hazard ratio 0.66; 95% CI, 0.32-1.32; P = 0.24). Cumulative incidence for the aggregated endpoint of acute decompensation of HF and/or death at 1 and 3 months were significatively lower in the levosimendan group than in placebo group [5.7% vs. 25.9% (P = 0.004) and 17.1% vs. 48.1% (P = 0.001), respectively], but not at 6 and 12 months [34.2% vs. 59.2% (P = 0.025); 41.4% vs. 66.6% (P = 0.022), respectively]. Survival probability was significantly higher in patients who received levosimendan compared with those who received placebo (log rank: 4.06; P = 0.044). There were no clinically relevant differences in tolerability between levosimendan and placebo and no new safety signals were observed. CONCLUSIONS: In our study, intermittent levosimendan in patients with AdHF produced a statistically non-significant reduction in the incidence of hospital readmissions for acute decompensated HF, a significantly lower cumulative incidence of acute decompensation of HF and/or death at 1 and 3 month of treatment and a significant improvement in survival during 12 months of treatment.

Role of Exercise Testing and Speckle Tracking Echocardiography in Paradoxical Severe Aortic Stenosis.

Introduction The clinical behavior and prognosis of patients with asymptomatic paradoxical low-gradient aortic stenosis (PLGAS) still remain controversial. Some authors consider PLGAS as an echocardiographically poorly quantified moderate AS (MAS). We aimed to investigate the clinical behavior of PLGAS by comparing it with that of asymptomatic high-gradient aortic stenosis (HG-AS) and MAS using transthoracic echocardiography (TTE) with speckle tracking imaging (STI) and cardiopulmonary exercise testing (CPET). The hypothesis of our study is, unlike that described by other authors, to demonstrate the existence of clinical and echocardiographic differences between PLGAS and MAS. Methods A cohort of 113 patients was included and categorized into three groups according to AS type: MAS (n=63), HG-AS (n=29), and PLGAS (n=21). Patients' clinical data were obtained. Patients underwent 2D TTE with STI and CPET. Results There were no significant differences in the clinical variables between the three AS groups. In the multivariate multinomial logistic regression analysis, with PLGAS being the reference category, the most powerful variable for establishing a difference with HG-AS was the left ventricular mass (LVM) indexed by body-surface area (odds ratio [OR]=1.04, confidence interval (CI)=1.01-1.06, p<0.05). The MAS group showed less abnormal CPET (OR=0.198, CI=0.06-0.69, p<0.05), and higher left ventricle global longitudinal strain rate (GLSR) (OR=0.003, CI=0.00-0.35, p<0.05) than the PLGAS group. Conclusions TTE with STI and CPET established the clear differences between patients with asymptomatic PLGAS and those with asymptomatic MAS, as well as the similarities between patients with PLGAS and those with HG-AS. Our data identify PLGAS as a completely different entity from MAS.

Extracellular water/total body water ratio as predictor of mortality in hemodialysis patients.

BACKGROUND: Overhydration is a predictor of mortality in hemodialysis (HD) patients. Bioimpedance spectroscopy (BIS) is used to determine the body composition. Extracellular Water/Total Body Water (ECW/TBW) ratio has been proposed to predict mortality. METHODS: Multicenter, prospective, observational, proof-of-concept study to estimate the impact of ECW/TBW in global and cardiovascular mortality and the relationship with cardiovascular biomarkers. The study included 60 patients (mean age, 71.8 ± 11.4 years; mean time on HD, 52.3 ± 30.8 months) with a median follow-up of 30.5 months (IQ range, 17.2-34 months). RESULTS: Post-dialysis ECW/TBW was directly associated with NT-proBNP and cTnT. During the study 28 patients died, most of them (43%) due to cardiovascular events. Compared to the survivors, these subjects had a higher post-dialysis ECW/TBW ratio (p = 0.006), while for cardiovascular mortality the only significant difference was a higher pre-dialysis ECW/TBW. The ability of post-dialysis ECW/TBW ratio to predict all-cause mortality had an area under the ROC curve (AUC) of 0.71 (CI 95%, 0.57-0.81; p = 0.002), with a cutoff point of 0.5023. For cardiovascular mortality the AUC was 0.66 (CI 95%, 0.52-0.77; p = 0.045), with a cutoff point of 0.4713. CONCLUSIONS: The post-dialysis ECW/TBW ratio measured by BIS can be a predictor of all-cause and cardiovascular mortality.

Iohexol plasma clearance simplified by Dried Blood Spot (DBS) sampling to measure renal function in conscious mice.

There is no simple method to measure glomerular filtration rate (GFR) in mice, which limits the use of mice in models of renal diseases. We aimed at simplifying the plasma clearance of iohexol in mice, using dried blood spot (DBS) sampling in order to reduce the amount of blood taken for analysis. GFR was measured simultaneously by a reference method in total blood-as described before-and tested method using DBS in fifteen male and six female C57BL/6J mice. Total blood extraction was 50 µL for the reference methods and 25µL for the tested methods, distributed in 5 samples. The agreement of GFR values between both methods was analyzed with the concordance correlation coefficient (CCC), total deviation index (TDI) and coverage probability (CP). The agreement between both methods was excellent, showing a TDI = 8.1%, which indicates that 90% of the GFR values obtained with DBS showed an error ranging from - 8 to + 8% of the reference method; a CCC of 0.996 (CI: 0.992), reflecting high precision and accuracy and a CP of 94 (CI: 83), indicating that 6% of the GFR values obtained with DBS had an error greater than 10% of the method in blood. So, both methods are interchangeable. DBS represent a major simplification of GFR measurement in mice. Also, DBS improves animal welfare by reducing the total blood required and refining the procedure.