Prediction of major adverse cardiac, cerebrovascular events in patients with diabetes after acute coronary syndrome.

BACKGROUND AND OBJECTIVES: The risk of major adverse cardiac and cerebrovascular events following acute coronary syndrome is increased in people with diabetes. Predicting out-of-hospital outcomes upon follow-up remains difficult, and no simple, well-validated tools exist for this population at present. We aim to evaluate several factors in a competing risks model for actionable evaluation of the incidence of major adverse cardiac and cerebrovascular events in diabetic outpatients following acute coronary syndrome. METHODS: Retrospective analysis of consecutive patients admitted for acute coronary syndrome in two centres. A Fine-Gray competing risks model was adjusted to predict major adverse cardiac and cerebrovascular events and all-cause mortality. A point-based score is presented that is based on this model. RESULTS: Out of the 1400 patients, there were 783 (55.9%) with at least one major adverse cardiac and cerebrovascular event (417 deaths). Of them, 143 deaths were due to non-major adverse cardiac and cerebrovascular events. Predictive Fine-Gray models show that the 'PG-HACKER' risk factors (gender, age, peripheral arterial disease, left ventricle function, previous congestive heart failure, Killip class and optimal medical therapy) were associated to major adverse cardiac and cerebrovascular events. CONCLUSION: The PG-HACKER score is a simple and effective tool that is freely available and easily accessible to physicians and patients. The PG-HACKER score can predict major adverse cardiac and cerebrovascular events following acute coronary syndrome in patients with diabetes.

Corneal Biomechanics in Unilateral Keratoconus and Fellow Eyes with a Scheimpflug-based Tonometer.

SIGNIFICANCE: Before the appearance of evident keratoconus, corneal biomechanical changes may be detectable. Here, these properties are analyzed to detect any difference that could help in the early recognition of keratoconus to allow patients to benefit from early treatments and to avoid refractive procedures in these corneas. PURPOSE: The purpose of this study was to compare corneal biomechanical characteristics as determined by Corvis Scheimpflug Technology tonometry between normal eyes and asymmetric keratoconic eyes. METHODS: Retrospective data from normal eyes (n = 100), keratoconic eyes (n = 18), and their topographically normal fellow eyes (n = 18) were analyzed. Differences in the variables among the groups were determined. For the parameters that showed significant differences, the receiver operating characteristic curve and the area under the curve (AUC) were used to assess the diagnostic accuracy of each variable. The optimal cutoff points were determined when comparing normal and fellow eyes. Also, a new linear combination of variables was performed to obtain better discriminative values. RESULTS: The following variables differed significantly between normal and fellow eyes: length of the flattened cornea in the second applanation, peak distance, curvature radius at highest concavity, and central corneal thickness. When each variable was independently considered, AUCs, sensitivity, and specificity were insufficiently high for good discrimination between the two groups. However, using a linear combination of variables, an optimal cutoff point (0.157) was obtained with an AUC of 0.78, sensitivity of 0.84, and specificity of 0.69. CONCLUSIONS: A best predictive linear combination of corneal biomechanical variables was tested including diameter of the flattened cornea in the second applanation and central corneal thickness. This combination was considered as the best in terms of its prediction capacity, simplicity and clinical application. This formula may be useful in clinical practice to discriminate between normal eyes and incipient keratoconus.

Confidence intervals for the symmetry point: an optimal cutpoint in continuous diagnostic tests.

Continuous diagnostic tests are often used for discriminating between healthy and diseased populations. For this reason, it is useful to select an appropriate discrimination threshold. There are several optimality criteria: the North-West corner, the Youden index, the concordance probability and the symmetry point, among others. In this paper, we focus on the symmetry point that maximizes simultaneously the two types of correct classifications. We construct confidence intervals for this optimal cutpoint and its associated specificity and sensitivity indexes using two approaches: one based on the generalized pivotal quantity and the other on empirical likelihood. We perform a simulation study to check the practical behaviour of both methods and illustrate their use by means of three real biomedical datasets on melanoma, prostate cancer and coronary artery disease.

Surface raw electromyography has a moderate discriminatory capacity for differentiating between healthy individuals and those with TMD: a diagnostic study.

The use of surface electromyography (sEMG) to identify subjects with chronic temporomandibular disorders (TMD) is controversial. The main objective of this study is to determine the diagnostic accuracy of EMG to differentiate between healthy subjects and those with TMD. This study evaluated 53 individuals with TMD who were referred to the university service and who fulfilled the eligibility criteria during the period of the study. Thirty-eight dental students were also recruited satisfying same eligibility criteria but without TMD. The inclusion criteria were to be fully dentate, have normal occlusion, and be righthanded. The exclusion criteria were periodontal pathology, caries or damaged dental tissues, orthodontic therapy, maxillofacial disease, botulinum A toxin therapy, and psychological disorders. The means of the masseter muscles, right (RM) and left (LM), and temporalis muscles, right (RT) and left (LT), and intraindividual indexes during resting and during clenching were calculated. Raw sEMG activity was used to determine the cutoff points and calculate the diagnostic accuracy of sEMG. The diagnostic accuracy of these variables for a diagnosis of TMD was evaluated by using the Receiver Operating Characteristic (ROC) curve and the area under it (AUC). A new transformed diagnostic variable was obtained by using the Generalized Additive Models (GAM). Optimal cutoff points were obtained where the sensitivity and specificity were similar and by the Youden index. The highest estimated AUC was 0.660 (95% CI 0.605-0.871) corresponding to the rLT variable during rest. When rLT and rACTIVITY (differences divided by sums of temporalis versus masseter muscles) were considered as a linear combination, the AUC increased to 0.742 (95% CI; 0.783-0.934). In conclusion, the raw sEMG evaluation of rest provided moderate sensitivity and specificity to discriminate between healthy individuals and those with TMD. The use of the indexes (mainly assessing the dominance of temporalis over masseter muscles during rest) is strongly recommended to increase the discriminatory capacity of raw sEMG evaluation.

Radiological infrabony defects after impacted mandibular third molar extractions in young adults.

PURPOSE: To estimate the prevalence of infrabony defects and their healing at the distal aspect of mandibular second molars (M2s) after extraction of impacted mandibular third molars (M3s). MATERIALS AND METHODS: This prospective clinical study included 22 young healthy patients (21.03 ± 4.51 yr old). Thirty-seven surgical extractions of high-risk periodontal and mesioangular impacted M3s in close contact with adjacent M2s were performed. Radiographic bone height (RBH), radiographic infrabony defects (RIDs), and bone loss (BL) were recorded at baseline and 3, 6, and 12 months after surgery. RBH and RIDs were measured from the tip of a periodontal gauge to the root apex and to the cementoenamel junction of the M2, respectively; BL was calculated by dividing the length of the M2 root into thirds and categorized as slight, moderate, or severe. RESULTS: Only 26 extracted teeth were included in all radiographic assessments. Mean RID size at baseline was 4.54 ± 1.87 mm. At 12 months, an average recovery of 2.80 ± 2.36 mm (P < .001) was recorded, for a mean RID size of 1.78 ± 1.65 mm. Statistically significant differences in RBH and RIDs were found at all assessments (P < .05). Improved bone healing was registered during the postoperative period, with higher values during the first 3 months (1.3 mm; P < .01). Most RIDs of at least 4 mm associated with moderate or slight BL decreased to no larger than 3 mm without BL. For moderate BL, the bone gain pattern was gradual and continuous, whereas for slight BL, the pattern was variable. CONCLUSIONS: In young healthy patients, a high-risk periodontal impacted M3 leads to an RID of at least 4 mm associated with slight or moderate BL at the distal aspect of the M2, which decreases to no larger than 3 mm 12 months after surgery. Bone healing is clinically and statistically significant at 12 months, with the most notable changes at the first 3-month follow-up.

A study of in vivo degradation of two vital home bleaching gels.

This study investigated hydrogen peroxide (H2O2) concentration of two home bleaching gels, in their dispensing syringes and their degradation in vivo in intraoral bleaching trays. Two bleaching gels were studied, 7.5% hydrogen peroxide (HP) and 20% carbamide peroxide (CP). The concentration of H2O2 was determined in dispensing syringes. Twenty individuals were involved in this study. The gels were placed in trays of both arches and their degradation determined at 5, 10, 15, 20, 30, 40, 60 and 75 min. The concentrations of H2O2 in syringes were (HP) 8.12% and (CP) 7.95%. For the HP gel in custom-trays the concentration of H2O2 was 73% at 5 min and 42% after 75 min. In the 20% CP gel it was 75% at 5 min and 39% after 75 min. Activity decreased linearly up to 75 min, where the mean concentration of H2O2 exceeded 35% for the CP and HP gels.

Relationship between glycated hemoglobin and glucose concentrations in the adult Galician population: selection of optimal glycated hemoglobin cut-off points as a diagnostic tool of diabetes mellitus

Aims/hypothesis To analyze the relationship between glucose and glycated hemoglobin (HbA1c) in the adult Galician population, evaluate the use of HbA1c for the screening and diagnosis of diabetes, and calculate the diagnostic threshold required for this purpose. Methods We analyzed data on 2848 subjects (aged 18-85 years) drawn from a study undertaken in 2004 to assess the prevalence of diabetes in Galicia. For study purposes, diabetes was defined using the criteria recommended in 2002. Participants were classified into four glucose-based groups. The relationship between glucose and HbA1c was described using linear regression models, generalized additive models and Spearman's correlation. Diagnostic capacity was assessed, and optimal HbA1c cut-off points were calculated as a diabetes marker using the receiver operating characteristic curve. Results Prevalence of pre-diabetes, unknown diabetes and known diabetes was 20.86, 3.37 and 4.39%, respectively. The correlations between HbA1c and fasting glucose were higher than those obtained for HbA1c and glycemia at 2h of the oral glucose overload (0.344 and 0.270, respectively). Taking glucose levels as the gold standard, a greater discriminatory capacity was obtained for HbA1c (area under de cruve: 0.839, 95% confidence intervals: 0.788-0.890). Based on the study criteria, the optimal minimum and maximum HbA1c values were 5.9% and 6.7%, respectively. Conclusions/interpretationHbA1c did not prove superior to glycemia for diagnosis of diabetes in the adult Galician population, and cannot therefore be used to replace the oral glucose tolerance test for screening and diagnosis purposes. Indeed, determination of glucose is essential to verify the diagnosis in the majority of cases (AU)

Objetivos/hipótesis: Analizar la relación entre la glucosa y la hemoglobina glucosilada (HbA1c)en la población gallega adulta, evaluar el uso de la HbA1c para cribado y diagnóstico de la diabetes y calcular el umbral diagnóstico necesario para este fin. Métodos: Se analizaron datos de 2.848 sujetos (de 18---85 años de edad) procedentes de un estudio emprendido en 2004 para valorar la prevalencia de diabetes en Galicia. A efectos del estudio, se definió la diabetes de acuerdo con los criterios recomendados en 2002. Se clasificó a los participantes en cuatro grupos en función de los valores de glucosa. Se describió la relación entre glucosa y HbA1c mediante modelos de regresión lineal, modelos aditivos generalizados yl a correlación de Spearman. Se valoró la capacidad diagnóstica y se calcularon los puntos de corte óptimos de la HbA1c como marcador de la diabetes empleando la curva de características operativas del receptor. Resultados: Las tasas de prevalencia de prediabetes, diabetes desconocida y diabetes conocidas eran del 10,86, 3,37 y 4,39%, respectivamente. Las correlaciones entre la HbA1c y la glucemia en ayunas eran mayores que las obtenidas entre la HbA1c y la glucemia en ayunas dos horas después de la sobrecarga oral de glucosa (0,344 y 0,270, respectivamente). Tomando los valores de glucosa como referencia, se obtuvo una mayor capacidad discriminatoria para la HbA1c (área bajo la curva: 0,839, intervalos de confianza del 95%: 0,788---0,890). Basándose en los criterios del estudio, los valores óptimos mínimos de la HbA1c eran del 5,9 y el 6,7%, respectivamente. Conclusiones/interpretación: La HbA1c no fue superior a la glucemia para el diagnóstico de la diabetes en la población gallega adulta, por lo que no puede utilizarse en lugar de la prueba de tolerancia oral a la glucosa con fines de cribado y diagnóstico. De hecho, la determinación de la glucosa es esencial para confirmar el diagnóstico en la mayoría de los casos (AU)

Mandibular second molar periodontal healing after impacted third molar extraction in young adults.

PURPOSE: To estimate the prevalence of preoperative periodontal defects and analyze 12-month spontaneous healing on the distal aspect of the mandibular second molar (M2) after impacted mandibular third molar (M3) extraction. MATERIALS AND METHODS: This prospective clinical study was conducted in 25 healthy young patients (21.03 ± 4.38 yr old) with 40 extractions of higher-risk periodontal impacted M3s. Plaque and gingival indexes, recession, bleeding on probing, probing depth (PD), and attachment level were recorded before surgery and at 3, 6, and 12 months after surgery at 5 sites on the distal aspect of the M2. RESULTS: The initial mean PD was 5.70 ± 3.80 mm, with the deepest mean PD at the lingual side. At 12 months, a mean PD average of 3.77 ± 2.86 mm was recorded, with a total average recovery of 1.93 ± 2.46 mm (P < .001), that was higher at 3 months (-1.62 mm, P < .001). The PD and attachment level improvements were statistically significant (P < .001) and nearly clinically significant from baseline to 12-month follow-up and from the buccal to the lingual side of the distal aspect of the M2. CONCLUSIONS: Impacted M3s adjacent to M2s lead to periodontal defects that are deepest at the lingual side and almost recover at 12 months after extraction. The first 3 months is considered the cutoff for periodontal healing. Young adults with high-risk periodontal M3 impactions may benefit from early extraction, which increases spontaneous periodontal healing.

Relationship between glycated hemoglobin and glucose concentrations in the adult Galician population: selection of optimal glycated hemoglobin cut-off points as a diagnostic tool of diabetes mellitus.

AIMS/HYPOTHESIS: To analyze the relationship between glucose and glycated hemoglobin (HbA(1c)) in the adult Galician population, evaluate the use of HbA(1c) for the screening and diagnosis of diabetes, and calculate the diagnostic threshold required for this purpose. METHODS: We analyzed data on 2848 subjects (aged 18-85 years) drawn from a study undertaken in 2004 to assess the prevalence of diabetes in Galicia. For study purposes, diabetes was defined using the criteria recommended in 2002. Participants were classified into four glucose-based groups. The relationship between glucose and HbA(1c) was described using linear regression models, generalized additive models and Spearman's correlation. Diagnostic capacity was assessed, and optimal HbA(1c) cut-off points were calculated as a diabetes marker using the receiver operating characteristic curve. RESULTS: Prevalence of pre-diabetes, unknown diabetes and known diabetes was 20.86, 3.37 and 4.39%, respectively. The correlations between HbA(1c) and fasting glucose were higher than those obtained for HbA(1c) and glycemia at 2h of the oral glucose overload (0.344 and 0.270, respectively). Taking glucose levels as the gold standard, a greater discriminatory capacity was obtained for HbA(1c) (area under de cruve: 0.839, 95% confidence intervals: 0.788-0.890). Based on the study criteria, the optimal minimum and maximum HbA(1c) values were 5.9% and 6.7%, respectively. CONCLUSIONS/INTERPRETATION: HbA(1c) did not prove superior to glycemia for diagnosis of diabetes in the adult Galician population, and cannot therefore be used to replace the oral glucose tolerance test for screening and diagnosis purposes. Indeed, determination of glucose is essential to verify the diagnosis in the majority of cases.

Temporal and spatial patterns in the rate of alcohol withdrawal syndrome in a defined community.

There is a paucity of data about the epidemiology of alcohol withdrawal syndrome (AWS) and, particularly, with regard to temporal trends and sociodemographic factors. This study included 7,195 episodes of AWS in a defined community (Galicia, Spain) over a 11-year period. We looked for geographical correlations between AWS rate and sociodemographic factors (education and socioeconomic levels and rates of occupational activity and unemployment) within respective districts. We also investigated the inter- and intra-annual time trends for AWS. The median age of the participants was 49 years (interquartile range, 41-60 years), and 85% were men. The annual frequency of AWS episodes remained stable during the study period, with a consistent peak in episodes during the summer months and lowest frequency of episodes in winter months (P<.001). The age- and sex-adjusted geographical distribution of the AWS rate was uneven; districts with high rate tended to cluster. The mean education level was negatively correlated with AWS rate within a given district after adjusting for socioeconomic level, occupational activity rate, and unemployment rate (P<.001). In conclusion, we identified characteristic temporospatial patterns of AWS rate in this defined community. The rate of AWS tended to be higher in the summer months and lower in the winter months. The rate of AWS was higher in districts with low education levels.

Variabilidad del parto en España. Análisis del conjunto mínimo básico de datos al alta hospitalaria / Variability in delivery in Spain. Analysis of the minimum data set for hospital discharges

Objetivo Describir las variaciones existentes en las tasas de utilización de los diversos procedimientos relacionados con el parto, en las diferentes comunidades autónomas españolas, provincias y tipos de hospital. Sujetos y métodos Estudio transversal; la unidad de análisis fueron los partos realizados en España (2001-2006) y la fuente de información, el CMBD al alta hospitalaria. Se realizó una agregación de los datos y un análisis descriptivo en función de las variables de estudio. ResultadosEl número de partos se incrementó en España a un ritmo de 10.000-15.000 partos al año. El porcentaje de partos no instrumentados fue del 62,7%, el de partos instrumentados del 15,1% y el de cesáreas del 22,2%. Se observó una gran variabilidad en todos los procedimientos estudiados, tanto entre provincias, como CCAA o tipos de hospitales. Conclusiones Los resultados obtenidos muestran la gran variabilidad existente en la asistencia al parto, tanto desde el punto de vista temporal, geográfico, y de la práctica clínica (AU)

Objective To describe variations in the utilization rates of distinct delivery-related procedures in the various autonomous regions, provinces and types of hospital in Spain. Subjects and methods A cross-sectional study was conducted, using the number of deliveries performed in Spain (2001-2006) as the unit of analysis, together with data drawn from the Minimum Data Set (MDS) for hospitable discharges. Data were pooled and a descriptive analysis was performed according to the study variables.ResultsThe number of childbirths in Spain increased at a rate of 10,000 to 15,000 per annum. The percentage breakdown of deliveries was as follows: non-instrumental 62.7%; instrumental, 15.1%; and cesarean section, 22.2%. There was wide variability in all the procedures studied among provinces, autonomous regions and types of hospital. Conclusions The results obtained highlight the wide variability in delivery in Spain in terms of time and geography, as well as of clinical practice (AU)