Valor del indice urea/creatinina en orina aislada para estimar el hipercatabolismo proteico grave en pacientes ventilados / Value of the urea/creatinine index in isolated urine to estimate severe protein hypercatabolism in ventilated patients

RESUMEN Objetivo: Estudiar la capacidad discriminativa de hipercatabolismo proteico grave del índice urea/creatinina en orina aislada en pacientes críticos ventilados. Metodos: Estudio prospectivo, observacional. Incluyó 52 pacientes sin insuficiencia renal. Variables: nitrógeno urinario total estimado a partir de la urea en orina de 24 horas al segundo (T1) y cuarto día (T2) e índice urea/creatinina en orina aislada previo a la recolección de orina de 24 horas. Resultados: Presentaron hipercatabolismo proteico grave (nitrógeno urinario total estimado > 15g) 14 pacientes (26,9%) en T1 y 29 (55,7%) en T2. El 84% de los pacientes presentaron bajo riesgo nutricional por la escala Nutrition Risk in the Critically Ill. En el segundo día, la correlación de Pearson del nitrógeno urinario total estimado con el índice urea/creatinina fue: 0,272 (p = 0,051) y en el cuarto día: 0,276 (p = 0,048). El índice urea/creatinina al cuarto día, tuvo una tendencia a mayor discriminación del hipercatabolismo proteico grave que el Acute Physiology and Chronic Health Evaluation II y Nutrition Risk in the Critically Ill (AUC 0,741 versus 0,669 y 0,656, IC95%: 0,602 - 0,880; 0,519 - 0,818 y 0,506 - 0,806 respectivamente). El valor de corte optimo del índice urea/creatinina para diagnóstico de hipercatabolismo proteico grave fue de 16,15 con una sensibilidad de 79,31% (IC95%: 59,74 - 91,29), especificidad de 60,87% (IC95%: 38,78 - 79,53), valor predictivo positivo 71,88% (IC95%: 53,02 - 85,60), valor predictivo negativo 70,0% (IC95%: 45,67 - 87,18), LR (+) 2,03 (IC95%: 1,18 - 3,49) y LR (-) 0,34 (IC95%: 0,16 - 0,74). Conclusión: El índice urea/creatinina realizado al cuarto día tiene un discreto valor para estimar el hipercatabolismo proteico grave por nitrógeno urinario total y no reemplaza al mismo en pacientes críticos ventilados sin falla renal. Por su razonable sensibilidad podría ser utilizado como cribado para identificar a quien tomar la muestra de orina de 24 horas.

ABSTRACT Objective: To study the ability of the urea/creatinine index to identify severe protein catabolism from the isolated urine of critically ventilated patients. Methods: This was a prospective, observational study. It included 52 patients without kidney failure. Variables: total urinary nitrogen estimated from the urea in 24-hour urine on the second (T1) and fourth days (T2) and urea/creatinine index in isolated urine before 24-hour urine collection. Results: Severe protein hypercatabolism (estimated total urinary nitrogen > 15g) was present in 14 patients (26.9%) at T1 and in 29 (55.7%) at T2. Eighty-four percent of patients had low nutritional risk by the Nutrition Risk in the Critically Ill score. At T1, the Pearson correlation between the estimated total urinary nitrogen and the urea/creatinine index was 0.272 (p = 0.051), and at T2 it was 0.276 (p = 0.048). The urea/creatinine index at T2 had a tendency to better discriminate severe protein hypercatabolism than Acute Physiology and Chronic Health Evaluation II and Nutrition Risk in the Critically Ill (AUC 0.741 versus 0.669 and 0.656, 95%CI: 0.602 - 0.880; 0.519 - 0.818 and 0.506 - 0.806, respectively). The optimal cutoff value of the urea/creatinine index for the diagnosis of severe protein hypercatabolism was 16.15, with a sensitivity of 79.31% (95%CI: 59.74 - 91.29), specificity of 60.87% (95%CI: 38.78 - 79.53), positive predictive value 71.88% (95%CI: 53.02 - 85.60), negative predictive value 70.0% (95%CI: 45.67 - 87.18), LR (+) 2.03 (95%CI: 1.18 - 3.49), and LR (-) 0.34 (95%CI: 0.16 - 0.74). Conclusion: The urea/creatinine index measured on the fourth day has a certain ability to estimate severe protein hypercatabolism (as defined by estimated total urinary nitrogen) but does not replace total urinary nitrogen in critically ventilated patients without kidney failure. Due to its reasonable sensitivity, it could be used as a screen to identify which patients to take a 24-hour urine sample from.

Value of the urea/creatinine index in isolated urine to estimate severe protein hypercatabolism in ventilated patients. / Valor del indice urea/creatinina en orina aislada para estimar el hipercatabolismo proteico grave en pacientes ventilados.

OBJECTIVE: To study the ability of the urea/creatinine index to identify severe protein catabolism from the isolated urine of critically ventilated patients. METHODS: This was a prospective, observational study. It included 52 patients without kidney failure. Variables: total urinary nitrogen estimated from the urea in 24-hour urine on the second (T1) and fourth days (T2) and urea/creatinine index in isolated urine before 24-hour urine collection. RESULTS: Severe protein hypercatabolism (estimated total urinary nitrogen > 15g) was present in 14 patients (26.9%) at T1 and in 29 (55.7%) at T2. Eighty-four percent of patients had low nutritional risk by the Nutrition Risk in the Critically Ill score. At T1, the Pearson correlation between the estimated total urinary nitrogen and the urea/creatinine index was 0.272 (p = 0.051), and at T2 it was 0.276 (p = 0.048). The urea/creatinine index at T2 had a tendency to better discriminate severe protein hypercatabolism than Acute Physiology and Chronic Health Evaluation II and Nutrition Risk in the Critically Ill (AUC 0.741 versus 0.669 and 0.656, 95%CI: 0.602 - 0.880; 0.519 - 0.818 and 0.506 - 0.806, respectively). The optimal cutoff value of the urea/creatinine index for the diagnosis of severe protein hypercatabolism was 16.15, with a sensitivity of 79.31% (95%CI: 59.74 - 91.29), specificity of 60.87% (95%CI: 38.78 - 79.53), positive predictive value 71.88% (95%CI: 53.02 - 85.60), negative predictive value 70.0% (95%CI: 45.67 - 87.18), LR (+) 2.03 (95%CI: 1.18 - 3.49), and LR (-) 0.34 (95%CI: 0.16 - 0.74). CONCLUSION: The urea/creatinine index measured on the fourth day has a certain ability to estimate severe protein hypercatabolism (as defined by estimated total urinary nitrogen) but does not replace total urinary nitrogen in critically ventilated patients without kidney failure. Due to its reasonable sensitivity, it could be used as a screen to identify which patients to take a 24-hour urine sample from.

OBJETIVO: Estudiar la capacidad discriminativa de hipercatabolismo proteico grave del índice urea/creatinina en orina aislada en pacientes críticos ventilados. METODOS: Estudio prospectivo, observacional. Incluyó 52 pacientes sin insuficiencia renal. Variables: nitrógeno urinario total estimado a partir de la urea en orina de 24 horas al segundo (T1) y cuarto día (T2) e índice urea/creatinina en orina aislada previo a la recolección de orina de 24 horas. RESULTADOS: Presentaron hipercatabolismo proteico grave (nitrógeno urinario total estimado > 15g) 14 pacientes (26,9%) en T1 y 29 (55,7%) en T2. El 84% de los pacientes presentaron bajo riesgo nutricional por la escala Nutrition Risk in the Critically Ill. En el segundo día, la correlación de Pearson del nitrógeno urinario total estimado con el índice urea/creatinina fue: 0,272 (p = 0,051) y en el cuarto día: 0,276 (p = 0,048). El índice urea/creatinina al cuarto día, tuvo una tendencia a mayor discriminación del hipercatabolismo proteico grave que el Acute Physiology and Chronic Health Evaluation II y Nutrition Risk in the Critically Ill (AUC 0,741 versus 0,669 y 0,656, IC95%: 0,602 - 0,880; 0,519 - 0,818 y 0,506 - 0,806 respectivamente). El valor de corte optimo del índice urea/creatinina para diagnóstico de hipercatabolismo proteico grave fue de 16,15 con una sensibilidad de 79,31% (IC95%: 59,74 - 91,29), especificidad de 60,87% (IC95%: 38,78 - 79,53), valor predictivo positivo 71,88% (IC95%: 53,02 - 85,60), valor predictivo negativo 70,0% (IC95%: 45,67 - 87,18), LR (+) 2,03 (IC95%: 1,18 - 3,49) y LR (-) 0,34 (IC95%: 0,16 - 0,74). CONCLUSIÓN: El índice urea/creatinina realizado al cuarto día tiene un discreto valor para estimar el hipercatabolismo proteico grave por nitrógeno urinario total y no reemplaza al mismo en pacientes críticos ventilados sin falla renal. Por su razonable sensibilidad podría ser utilizado como cribado para identificar a quien tomar la muestra de orina de 24 horas.

[Relationship between the NUTRIC nutritional risk scale and protein hypercatabolism in critically ventilated patients]. / Relación entre la escala de riesgo nutricional NUTRIC y el hipercatabolismo proteico en pacientes críticos ventilados.

INTRODUCTION: the Nutrition Risk in Critically Ill (NUTRIC) score does not include a variable that objectively estimates protein hypercatabolism (PHC), one of the main metabolic changes experienced by critical patients. OBJECTIVE: to evaluate the correlation of the NUTRIC score with PHC in critically ventilated patients. MATERIALS AND METHODS: prospective, observational study. Mixed ICU. It included ventilated patients ≥ 18 years old, without anuria or chronic renal failure. The modified NUTRIC score, which replaces IL-6 for PCR, was obtained at admission and 24-hour urine was collected at the 2nd (T0) and 4th day (T1) to determine the total urinary nitrogen (TUN). RESULTS: a total of 69 patients were included. Average age: 43 years (± 17.01); 73% were males. Admission pathologies: trauma (39%) and sepsis (20%). APACHE II: 17 (± 6.66). Seventeen patients presented acute renal failure (ARF). NUTRIC score mean: 3.13 (± 1.94); 84% presented low nutritional risk. The Pearson correlation between NUTRIC and TUN in T0 and T1 was: -0.150 (p: 0.218) and -0.053 (p: 0.663). The mean length of staying in ICU and mechanical ventilation was: 13.35 (± 12.37) and 9.84 (± 10.82) days, respectively. Mortality in ICU: 36%. In the non-ARF subgroup with low risk according to NUTRIC score, 27% presented severe PHC at T0 and 52% at T1. The correlation was: 0.070 (p: 0.620) and 0.138 (p: 0.329), respectively. CONCLUSION: no correlation was found between the estimators of the stress metabolic response of the NUTRIC score and the PHC in critically ill patients ventilated; therefore, it would not be possible to substitute the measurement of the same in the assessment of the nutritional risk.

INTRODUCCIÓN: la escala de riesgo nutricional NUTRIC no incluye una variable que estime en forma objetiva el hipercatabolismo proteico (HCP), una de las principales alteraciones metabólicas que experimentan los pacientes críticos. OBJETIVO: evaluar la correlación de la escala NUTRIC con el HCP en pacientes críticos ventilados. MATERIAL Y MÉTODOS: estudio prospectivo, observacional. UCI polivalente. Incluyó pacientes ≥ 18 años, ventilados, sin anuria ni insuficiencia renal crónica. La variante del NUTRIC, que remplaza la IL-6 por PCR se obtuvo al ingreso y se recolectó orina de 24 horas al segundo (T0) y cuarto día (T1) para determinar el nitrógeno urinario total (NUT). RESULTADOS: se incluyeron 69 pacientes. Edad media: 43 años (± 17,01); el 73% eran varones. Patologías de ingreso: trauma (39%) y sepsis (20%). APACHE II: 17 (± 6,66). Presentaron insuficiencia renal aguda (IRA) 17 pacientes. NUTRIC medio: 3,13 (± 1,94). El 84% presentó bajoriesgo nutricional. La correlación de Pearson entre NUTRIC y NUT en T0 y T1 fue de -0,150 (p: 0,218) y -0,053 (p: 0,663). La media de internación y ventilación mecánica fue de 13,35 (± 12,37) y 9,84 (± 10,82) días, respectivamente. Mortalidad en UCI: 36%. En el subgrupo sin IRA con bajo riesgo por NUTRIC el 27% presentó HCP severo en T0 y el 52% en T1. La correlación fue: 0,070 (p: 0,620) y 0,138 (p: 0,329), respectivamente. CONCLUSIÓN: no se halló correlación entre los estimadores de la respuesta metabólica de estrés de la escala NUTRIC y el HCP en pacientes críticos ventilados; por lo tanto, no se podría sustituir la medición real del mismo en la valoración del riesgo nutricional.

Relación entre la escala de riesgo nutricional NUTRIC y el hipercatabolismo proteico en pacientes críticos ventilados / Relationship between the NUTRIC nutritional risk scale and protein hypercatabolism in critically ventilated patients

Introducción: la escala de riesgo nutricional NUTRIC no incluye una variable que estime en forma objetiva el hipercatabolismo proteico (HCP), una de las principales alteraciones metabólicas que experimentan los pacientes críticos. Objetivo: evaluar la correlación de la escala NUTRIC con el HCP en pacientes críticos ventilados. Material y métodos: estudio prospectivo, observacional. UCI polivalente. Incluyó pacientes ≥ 18 años, ventilados, sin anuria ni insuficiencia renal crónica. La variante del NUTRIC, que remplaza la IL-6 por PCR se obtuvo al ingreso y se recolectó orina de 24 horas al segundo (T0) y cuarto día (T1) para determinar el nitrógeno urinario total (NUT). Resultados: se incluyeron 69 pacientes. Edad media: 43 años (± 17,01); el 73% eran varones. Patologías de ingreso: trauma (39%) y sepsis (20%). APACHE II: 17 (± 6,66). Presentaron insuficiencia renal aguda (IRA) 17 pacientes. NUTRIC medio: 3,13 (± 1,94). El 84% presentó bajo riesgo nutricional. La correlación de Pearson entre NUTRIC y NUT en T0 y T1 fue de -0,150 (p: 0,218) y -0,053 (p: 0,663). La media de internación y ventilación mecánica fue de 13,35 (± 12,37) y 9,84 (± 10,82) días, respectivamente. Mortalidad en UCI: 36%. En el subgrupo sin IRA con bajo riesgo por NUTRIC el 27% presentó HCP severo en T0 y el 52% en T1. La correlación fue: 0,070 (p: 0,620) y 0,138 (p: 0,329), respectivamente. Conclusión: no se halló correlación entre los estimadores de la respuesta metabólica de estrés de la escala NUTRIC y el HCP en pacientes críticos ventilados; por lo tanto, no se podría sustituir la medición real del mismo en la valoración del riesgo nutricional

Introduction: the Nutrition Risk in Critically Ill (NUTRIC) score does not include a variable that objectively estimates protein hypercatabolism (PHC), one of the main metabolic changes experienced by critical patients. Objective: to evaluate the correlation of the NUTRIC score with PHC in critically ventilated patients. Material and methods: prospective, observational study. Mixed ICU. It included ventilated patients ≥ 18 years old, without anuria or chronic renal failure. The modified NUTRIC score, which replaces IL-6 for PCR, was obtained at admission and 24-hour urine was collected at the 2nd (T0) and 4th day (T1) to determine the total urinary nitrogen (TUN). Results: a total of 69 patients were included. Average age: 43 years (± 17.01); 73% were males. Admission pathologies: trauma (39%) and sepsis (20%). APACHE II: 17 (± 6.66). Seventeen patients presented acute renal failure (ARF). NUTRIC score mean: 3.13 (± 1.94); 84% presented low nutritional risk. The Pearson correlation between NUTRIC and TUN in T0 and T1 was: -0.150 (p: 0.218) and -0.053 (p: 0.663). The mean length of staying in ICU and mechanical ventilation was: 13.35 (± 12.37) and 9.84 (± 10.82) days, respectively. Mortality in ICU: 36%. In the non-ARF subgroup with low risk according to NUTRIC score, 27% presented severe PHC at T0 and 52% at T1. The correlation was: 0.070 (p: 0.620) and 0.138 (p: 0.329), respectively. Conclusion: no correlation was found between the estimators of the stress metabolic response of the NUTRIC score and the PHC in critically ill patients ventilated; therefore, it would not be possible to substitute the measurement of the same in the assessment of the nutritional risk

Postdischarge Care of Pediatric Traumatic Brain Injury in Argentina: A Multicenter Randomized Controlled Trial.

OBJECTIVE: To develop, in partnership with families of children with traumatic brain injury, a postdischarge intervention that is effective, simple, and sustainable. DESIGN: Randomized Controlled Trial. SETTING: Seven Level 1 Pediatric Trauma Centers in Argentina. PATIENTS: Persons less than 19 years of age admitted to one of the study hospitals with a diagnosis of severe, moderate, or complicated mild traumatic brain injury and were discharged alive. INTERVENTIONS: Patients were randomly assigned to either the intervention or standard care group. A specially trained Community Resource Coordinator was assigned to each family in the intervention group. We hypothesized that children with severe, moderate, and complicated mild traumatic brain injury who received the intervention would have significantly better functional outcomes at 6 months post discharge than those who received standard care. We further hypothesized that there would be a direct correlation between patient outcome and measures of family function. MEASUREMENTS AND MAIN RESULTS: The primary outcome measure was a composite measured at 6 months post injury. There were 308 patients included in the study (61% men). Forty-four percent sustained a complicated mild traumatic brain injury, 18% moderate, and 38% severe. Sixty-five percent of the patients were 8 years old or younger, and over 70% were transported to the hospital without ambulance assistance. There was no significant difference between groups on the primary outcome measure. There was a statistically significant correlation between the primary outcome measure and the scores on the Family Impact Module of the Pediatric Quality of Life Inventory (ρ = 0.57; p < 0.0001). Children with better outcomes lived with families reporting better function at 6 months post injury. CONCLUSIONS: Although no significant effect of the intervention was demonstrated, this study represents the first conducted in Latin America that documents the complete course of treatment for pediatric patients with traumatic brain injury spanning hospital transport through hospital care and into the postdischarge setting.

Utilidad de los criterios de predicción clínica y del test rápido antigénico para el manejo de la faringitis aguda en un servicio de urgencias / Usefulness of clinical prediction criteria and rapid antigen detection testing for the management of acute pharyngitis in an emergency department

Objetivo: Validar los criterios de CENTOR modificados (CENTOR-m) y los tests rápidos de detección del antígeno de Estreptococo del Grupo A (SGA) en la faringitis aguda. Diseño: Estudio de validación de pruebas diagnósticas. Emplazamiento y participantes: Ciento un pacientes elegibles, que consultaron al departamento de urgencias de un hospital de tercer nivel con cuadro clínico compatible con faringitis aguda. Mediciones Principales: Se obtuvieron muestras de hisopados faríngeos para la realización del test rápido antigénico para SGA (FAMR) y para cultivo, respectivamente. Se calculó en cada caso los criterios de CENTOR-m. Resultados: La edad media de los pacientes incluidos en el estudio fue de 22,6 años (DE:13,8). El 48,5 % eran varones. El SGA fue el patógeno aislado en el 20,79 % de los casos. El CENTOR-m presentó una sensibilidad del 83,3 % (50,9 %-97,1 %), especificidad del 45,5 % (30,7 %-61,0 %) valor predictivo positivo (VPP) del 29,4 % (15,7 %-47,7 %) y valor predictivo negativo (VPN) del 90,9 % (69,4 %-98,4 %). El FAMR presento una sensibilidad del 81,5 % (61,3 %-93,0 %) especificidad del 98,6 % (91,4 %-99,9 %), VPP del 95,7 % (76,0 %-99,8 %) y VPN del 93,3 % (84,5 %-97,5 %). El 49,5 % de los pacientes recibieron antibióticos basándose en el juicio médico, lo que resultó en una proporción de sobreindicación de antimicrobianos del 62 %. Conclusiones: Los criterios de CENTOR-m demostraron adecuado valor pronóstico negativo y el FAMR buena sensibilidad, especificidad y valor pronóstico positivo para faringitis por SGA. La utilización de ambos métodos en la atención urgente podría optimizar el manejo de la patología y la adecuación antibiótica (AU)

Objective: To validate the modified CENTOR score (m-CENTOR) and the rapid antigen detection testing for group A streptococcus (GAS) in acute pharyngitis. Design: Diagnostic test validation study. Location and Participants: 101 eligible patients, who consulted at the emergency department in a third level Hospital with a clinical picture compatible with acute pharyngitis. Main measures: Pharyngeal swabs were obtained for culture and rapid antigen detection testing for group A Streptococcus (FAMR). CENTOR score was calculated for each case. Results: The average age of the patients included in the study was 22.6 years (SD: 13.8). The gender distribution was 48.5% males. The group A Streptococcus (GAS) was the pathogen isolated in the 20.79% of the cases. The m-CENTOR presented a sensibility of 83.3 %(50.9%-97.1%), specificity 45.5% (30.7%-61.0%), positive predictive value (PPV) of 29.4% (15.7%-47.7%) and negative predictive value (NPV) 90.9% (69.4%-98.4%). The FAMR presented a sensibility of 81.5% (61.3%-93.0%), specificity 98.6% (91.4%-99.9%) PPV 95.7% (76.0%-99.8%) and NPV 93.3% (84.5%-97.5%). 49.5% of the patients received antibiotics based on medical judgment, which resulted in a 62% increase in antimicrobial indication. Conclusions: The m-CENTOR score evidenced an accurate negative predictive value, and the FAMR presented good sensibility, specificity and positive predictive value for pharyngitis caused by GAS. The use of both methods in emergency care could optimize the management of the pathology and improve antibiotic adequacy (AU)

[Study of two variants of nutritional risk score "NUTRIC" in ventilated critical patients]. / Estudio de dos variantes de la puntuación de riesgo nutricional "NUTRIC" en pacientes críticos ventilados.

INTRODUCTION: The NUTRIC score was proposed to assess the risk of adverse events potentially modifiable through nutritional intervention in critically ill patients. This score uses interleukin-6 (IL-6), a biomarker not always available. OBJECTIVE: To study two variants of the score in patients with assisted mechanical ventilation (AMV): NUTRIC-1 without IL-6 and NUTRIC-2 with CRP as biomarker. METHODS: Observational prospective cohort with 368 patients with AMV >24 hours. The predictive capacity of both NUTRIC scores was studied by binary logistic regression. The significance level was set at 5%. RESULTS: mean age, 52 years; males 68%. Mean APACHE II score: 20.73 points. Death at the ICU: 196 (53%). Mean time on AMV of the survivals: 8.55 days. Mean NUTRIC-1 and NUTRIC-2 in the deceased-survivors: 4.23 - 3.06 (p = 0.000) and 4.68 -3.39 (p = 0.000). The mortality increased in relation to the score (p = 0.000). The calculated AUC for NUTRIC-1 and NUTRIC-2 were 0.671 (CI 0.617-0.726) and 0.679 (CI 0.624- 0.733). The mean CRP was higher in deceased patients: 13.07 mg/dL - 8.97 mg/dL (p = 0.001), the correlation improved with more days on AMV (p = 0.034 and p = 0.010) and the AUC increased in a similar way to IL-6 in the original work (0.008 and 0.007, respectively). CONCLUSION: The two studied variants of the NUTRIC score behaved similarly to the original NUTRIC score. The addition of the CRP improves the score performance and may be an alternative to IL-6, if it is not available.

Estudio de dos variantes de la puntuacion de riesgo nutricional "NUTRIC" en pacientes criticos ventilados / Study of two variants of nutritional risk score "NUTRIC" in ventilated critical patients

Introducción: La puntuación NUTRIC, propuesta para evaluar el riesgo de eventos adversos potencialmente modificables por la intervención nutricional en pacientes críticos, utiliza un biomarcador no siempre disponible, la Interleuquina-6 (IL-6). Objetivo: Estudiar en pacientes con asistencia ventilatoria mecánica (AVM) dos variantes de la puntuación: NUTRIC-1 sin IL-6 y NUTRIC-2 con PCR como biomarcador. Métodos: Cohorte prospectiva observacional de 368 enfermos con AVM >24 horas. La capacidad predictiva de las dos variantes del NUTRIC se estudió mediante regresión logística binaria. El nivel de significación utilizado fue de 5%. Resultados: Edad promedio: 52 años, varones: 68%. APACHE II promedio: 20,73 puntos. Fallecidos en la UCI: 196 (53%). Tiempo de AVM promedio de los sobrevivientes: 8,55 días. NUTRIC-1 y NUTRIC-2 promedio en fallecidos - sobrevivientes: 4,23 - 3,06 (p = 0,000) y 4,68 -3,39 (p = 0,000). La mortalidad aumentó en relación al incremento de la puntuación (p = 0,000). Las AUC calculadas para NUTRIC-1 y NUTRIC-2 fueron 0,671 (IC 0,617-0,726) y 0,679 (IC 0,624-0,733). La PCR promedio fue superior en los pacientes fallecidos: 13,07 mg/dl - 8,97 mg/dl (p = 0,001), mejoró la correlación con los días de AVM (p 0,034 y p 0,010) e incremento el AUC en forma similar a la IL-6 en el trabajo original (0,008 y 0,007 respectivamente). Conclusión: Las dos variantes de la puntuación estudiadas se comportaron en forma similar al NUTRIC original. La incorporación de la PCR mejora el rendimiento de dicha puntuación y podría ser una alternativa a la IL-6, de no estar disponible (AU)

Introduction: The NUTRIC score was proposed to assess the risk of adverse events potentially modifiable through nutritional intervention in critically ill patients. This score uses interleukin-6 (IL-6), a biomarker not always available. Objective: To study two variants of the score in patients with assisted mechanical ventilation (AMV): NUTRIC-1 without IL-6 and NUTRIC-2 with CRP as biomarker. Methods: Observational prospective cohort with 368 patients with AMV >24 hours. The predictive capacity of both NUTRIC scores was studied by binary logistic regression. The significance level was set at 5%. Results: mean age, 52 years; males 68%. Mean APACHE II score: 20.73 points. Death at the ICU: 196 (53%). Mean time on AMV of the survivals: 8.55 days. Mean NUTRIC-1 and NUTRIC-2 in the deceased-survivors: 4.23 - 3.06 (p = 0.000) and 4.68 -3.39 (p = 0.000). The mortality increased in relation to the score (p = 0.000). The calculated AUC for NUTRIC-1 and NUTRIC-2 were 0.671 (CI 0.617-0.726) and 0.679 (CI 0.6240.733). The mean CRP was higher in deceased patients: 13.07 mg/dL - 8.97 mg/dL (p = 0.001), the correlation improved with more days on AMV (p = 0.034 and p = 0.010) and the AUC increased in a similar way to IL-6 in the original work (0.008 and 0.007, respectively). Conclusion: The two studied variants of the NUTRIC score behaved similarly to the original NUTRIC score. The addition of the CRP improves the score performance and may be an alternative to IL-6, if it is not available (AU)

Leishmaniasis visceral: contribución a su control mediante el fortalecimiento del diagnóstico del reservorio canino en Posadas, Misiones, Argentina / Visceral leishmaniasis: control contribution by strengthening the diagnosis of dog reservoir in the city of Posadas, Misiones, Argentina

INTRODUCCION: La leishmaniasis visceral (LV) es una enfermedad emergente en Argentina. En 2006 se describió el primer caso autóctono en Posadas (Misiones), ciudad que se convirtió en epicentro de la LV.OBJETIVO: Determinar la prevalencia de la LV canica (LVC) y fortalecer su diagnóstico en Posadas.METODOS: Con un criterio entomológico, la ciudad de Posadas se dividió en islas de alta densidad (IAD) e islas de baja densidad (IBD) de flebótomos. Se seleccionó, de forma arbitraria y mediante imágenes satelitales, la manzana situada más al norte y más al sur de cada IAD e IBD. Se realizó un diseño observacional prospectivo, y se estudió a todos los perros de las manzanas seleccionadas. Se consideró un N inicial de 400 animales para detectar una diferencia de al menos 7% con una potencia de 0,90 y un nivel de 0,05 respecto de la prevalencia global supuesta del 20%. Se tomaron muestras de sangre, punción de ganglios linfáticos y raspado de piel. El estudio incluyó además un test serológico rápido (rK39 canino) y frotis de las muestras para búsqueda parasitológica, que se procesaron y evaluaron en el Instituto Municipal de Salud Animal de Posadas y en el Instituto Nacional de Parasitología Fatala Chabén.RESULTADOS: De los 182 animales evaluados, 33 fueron positivos para LVC, con una prevalencia global del 18,1%. En IAD la prevalencia fue 22% y en IBD, 13,4%. Los estudios parasitológicos fueron positivos en el 10% de los caninos en IAD y 1,2% en IBD. La LVC fue asintomática u oligosintomática, con una presentación más frecuente en IAD. La rK39 tuvo una sensibilidad del 90,3% y una especificidad del 98,9%.CONCLUSIONES: El análisis serológico con antígeno rK39 fue siempre más sensible que la búsqueda parasitológica para el diagnóstico. La LVC parece tener menor prevalencia en relación con estudios previos, quizás debido a diferentes medidas de control realizadas en el Municipio de Posadas.

INTRODUCCION: Visceral leishmanisis (VL) is an emerging disease in Argentina. The first autochthonous case was described in 2006 in a chld from Posadas (Misiones), the city which turned out to be the focus of VL.OBJECTIVE: To determine the prevalence of canine VL (CVL) and improve its diagnosis in Posadas.METHODS: According to entomological criteria, Posadas was divided in high density islands (HDI) and low density islands (LDI) of sandfly. Randomly and with satellite images, the northernmost and southernmost blocks of each HDI and LDI were selected. A prospective, experimental design was performed, studying all the dogs in the selected blocks. There was an initial sample of 400 animals to detect a difference of at least 7%, with a power of 0.90 and a level of 0.05, compared to the supposed prevalence of 20%. Blood samples were taken, with puncture of lymph nodes and skin scraping. The study also included a (canine rK39) rapid test for serological assessment adn sample smears for parasitological search. Samples were processed and evaluated in the Posadas institute of animal health (I.MU.S.A) and the Fatala Chabén National Institute of Parasitology.RESULTS: CVL was assessed in 33/182 animals with an overall prevalence of 18.1%. In HDI, the prevalence was 22%; in LDI, it was 13.4%. Parasitological studies were positive in 10% (HDI) and 1.2% (LDI). The CVL had a nonspecific clinical presentation; canines were asimptomatic or oligosymptomatic, with a higher trend in HDI. The rK39 had a sensitivity of 90.3% and a specificity of 98.9%.CONCLUSIONS: The antigen rK39 was always more sensitive than the search for parasites for the diagnosis of CVL. The disease appears to be less prevalent comapring to previous studies, perhaps due to different control measures performed in the Municipality of Posadas.

Leishmaniasis visceral: contribución a su control mediante el fortalecimiento del diagnóstico del reservorio canino en Posadas, Misiones, Argentina / Visceral leishmaniasis: control contribution by strengthening the diagnosis of dog reservoir in the city of Posadas, Misiones, Argentina

INTRODUCCION: La leishmaniasis visceral (LV) es una enfermedad emergente en Argentina. En 2006 se describió el primer caso autóctono en Posadas (Misiones), ciudad que se convirtió en epicentro de la LV.OBJETIVO: Determinar la prevalencia de la LV canica (LVC) y fortalecer su diagnóstico en Posadas.METODOS: Con un criterio entomológico, la ciudad de Posadas se dividió en islas de alta densidad (IAD) e islas de baja densidad (IBD) de flebótomos. Se seleccionó, de forma arbitraria y mediante imágenes satelitales, la manzana situada más al norte y más al sur de cada IAD e IBD. Se realizó un diseño observacional prospectivo, y se estudió a todos los perros de las manzanas seleccionadas. Se consideró un N inicial de 400 animales para detectar una diferencia de al menos 7% con una potencia de 0,90 y un nivel de 0,05 respecto de la prevalencia global supuesta del 20%. Se tomaron muestras de sangre, punción de ganglios linfáticos y raspado de piel. El estudio incluyó además un test serológico rápido (rK39 canino) y frotis de las muestras para búsqueda parasitológica, que se procesaron y evaluaron en el Instituto Municipal de Salud Animal de Posadas y en el Instituto Nacional de Parasitología Fatala Chabén.RESULTADOS: De los 182 animales evaluados, 33 fueron positivos para LVC, con una prevalencia global del 18,1%. En IAD la prevalencia fue 22% y en IBD, 13,4%. Los estudios parasitológicos fueron positivos en el 10% de los caninos en IAD y 1,2% en IBD. La LVC fue asintomática u oligosintomática, con una presentación más frecuente en IAD. La rK39 tuvo una sensibilidad del 90,3% y una especificidad del 98,9%.CONCLUSIONES: El análisis serológico con antígeno rK39 fue siempre más sensible que la búsqueda parasitológica para el diagnóstico. La LVC parece tener menor prevalencia en relación con estudios previos, quizás debido a diferentes medidas de control realizadas en el Municipio de Posadas.

INTRODUCCION: Visceral leishmanisis (VL) is an emerging disease in Argentina. The first autochthonous case was described in 2006 in a chld from Posadas (Misiones), the city which turned out to be the focus of VL.OBJECTIVE: To determine the prevalence of canine VL (CVL) and improve its diagnosis in Posadas.METHODS: According to entomological criteria, Posadas was divided in high density islands (HDI) and low density islands (LDI) of sandfly. Randomly and with satellite images, the northernmost and southernmost blocks of each HDI and LDI were selected. A prospective, experimental design was performed, studying all the dogs in the selected blocks. There was an initial sample of 400 animals to detect a difference of at least 7%, with a power of 0.90 and a level of 0.05, compared to the supposed prevalence of 20%. Blood samples were taken, with puncture of lymph nodes and skin scraping. The study also included a (canine rK39) rapid test for serological assessment adn sample smears for parasitological search. Samples were processed and evaluated in the Posadas institute of animal health (I.MU.S.A) and the Fatala Chabén National Institute of Parasitology.RESULTS: CVL was assessed in 33/182 animals with an overall prevalence of 18.1%. In HDI, the prevalence was 22%; in LDI, it was 13.4%. Parasitological studies were positive in 10% (HDI) and 1.2% (LDI). The CVL had a nonspecific clinical presentation; canines were asimptomatic or oligosymptomatic, with a higher trend in HDI. The rK39 had a sensitivity of 90.3% and a specificity of 98.9%.CONCLUSIONS: The antigen rK39 was always more sensitive than the search for parasites for the diagnosis of CVL. The disease appears to be less prevalent comapring to previous studies, perhaps due to different control measures performed in the Municipality of Posadas.

Congenital Trypanosoma cruzi infection. Efficacy of its monitoring in an urban reference health center in a non-endemic area of Argentina.

Congenital transmission (CT) has acquired relevance in Chagas disease (CHD). A cohort of pregnant CHD women (4,355) and their babies were studied in the period 1994-2004. Children were excluded when they had received blood transfusions, or were born or had been in endemic areas; CT rate was 6.1%. Babies were diagnosed between months 1 and 5 in 68.9% of the cases and between months 6 and 12 in 31.1%. In the latter group, parasitemia was detected in 94% and serology in 74.7%. Between months 6 and 9, parasitemia diagnosed 36.2% (P = 0.000) more cases than serology. If serology had been the diagnosis method, those children would have been considered CT free. Taking the overall outcomes, 38.1% of babies were CT free, and 55.8% did not complete the follow-up. Establishing CT as a public health priority and improving first-line health service, congenital CHD coverage could be more efficient in endemic countries.

Early prognosis of severe traumatic brain injury in an urban argentinian trauma center.

BACKGROUND: : Previous studies indicate that age, Glasgow Coma Scale score (GCS), arterial hypotension, computed tomography (CT) findings, and pupillary reactivity are strong predictors of outcome for patients with severe traumatic brain injury (TBI). However, the predictive validity of these variables has never been rigorously tested in patients from the developing world. The objective of this study was to evaluate the prognostic value of these variables in a resource-limited setting and to test their predictive power by using them to create an outcome model. METHODS: : The study was conducted at Hospital Emergencias "Dr. Clemente Alvarez" in Rosario, Argentina. All patients with severe TBI meeting criteria between August 2000 and February 2003 were included. Outcome at 6 months postinjury was measured by mortality and by the Extended Glasgow Outcome Scale score. Two logistic regression models were created for predicting mortality and outcome. RESULTS: : Outcome measures were acquired for 100% of the sample (N = 148). There was 58% mortality; 30% had moderate to good recovery, and 12% were severely disabled. The model accurately predicted 83.9% of mortality, and 81.1% of outcome. Because of variation in timing of CT scans, the models were recalculated without the CT variable. The accuracy of prediction was 79.7% and 79% for mortality and Extended Glasgow Outcome Scale, respectively. CONCLUSIONS: : This study provides rigorous, prospective data that (1) validates the generalizability of the five World Health Organization/Organization Mondiale de la Santé TBI prognostic predictors outside of the developed world, and (2) provides outcome benchmarks for mortality and morbidity from severe TBI in developing countries.