Eficacia de tres escalas pronósticas de mortalidad en la Unidad de Cuidados Intensivos del HGR No. 20 / Effectiveness of three forecast mortality scales in the Intensive Care Unit of HGR No. 20 / Eficácia de três escalas de prognóstico de mortalidade na Unidade de Terapia Intensiva do HGR No. 20

Resumen: Introducción: La Unidad de Cuidados Intensivos (UCI) es el área hospitalaria que se encarga de la atención médica integral de los pacientes en estado crítico, los cuales tienen altas posibilidades de recuperación. Las escalas pronósticas de mortalidad funcionan como indicadores objetivos y estandarizados para la categorización de pacientes en términos de gravedad y de esta manera estandarizar su ingreso a estas unidad, así como evaluar la eficacia y calidad de nuestra labor como médicos en estas UCI. Objetivo: Determinar cuál es la escala pronostica de mortalidad más eficaz para la UCI del HGR No. 20. Material y métodos: Se realizó estudio descriptivo, transversal, retrospectivo, comparativo en la UCI del HGR No. 20, durante el periodo comprendido del 1o de enero al 31 de diciembre de 2016. Se aplicaron tres escalas pronósticas de mortalidad APACHE II, SAPS II y SOFA, se determinó la eficacia del pronóstico de mortalidad dado por cada escala y se compararon los resultados entre las tres. Se realizó análisis estadístico por media estadística descriptiva, frecuencias, medidas de tendencia central, frecuencias para variables cualitativas. Estadística no paramétrica con χ2 para análisis bivariado, prueba de correlación de Kendall y regresión lineal, graficando con curva de ROC. Resultados: Se analizaron 244 expedientes de pacientes que ingresaron a la UCI, se encontraron los siguientes datos: 174 sobrevivientes y 70 defunciones para una mortalidad de 28.7%; con media de edad del 44.64 DE ± 17.9; por género 134 de sexo femenino y 110 masculinos; siendo la principal causa de ingreso pacientes postquirúrgicos 73 (29.9%) y pacientes con sepsis o choque séptico 54 (22.1%); en cuanto a las escalas pronósticas, la correlación APACHE II-SAPS II 0.784, APACHE II vs SOFA 0.761, SOFA vs SAPS II 0.723. y en regresión lineal SOFA con un coeficiente de B 0.208 y β 0.642. Conclusión: Existe una correlación entre una mayor mortalidad real a medida que aumenta la puntación con respecto a la escala APACHE y SAPS II. Realizando la regresión lineal podemos decir que SOFA tiene mayor susceptibilidad ante las otras escalas pronósticas APACHE II y SAPS II con un IC de 95%.

Abstract: Introduction: The intensive care unit (ICU) is the hospital area in the which is responsible for the comprehensive medical care of patients in critical condition which have high chances of recovery; the prognostic scales of mortality function as objective and standardized indicators for categorization of patients in terms of severity in this way standardize your admission to these units, as well as evaluating the effectiveness and quality of our work as doctors in these ICUs. Objective: To determine which is the most effective mortality prognostic scale for the ICU of the HGR No. 20. Material and methods: A descriptive, cross-sectional, retrospective study was carried out. Comparative in the ICU of HGR No. 20, during the period from 1° January to December 31, 2016. Three forecast scales of mortality APACHE II, SAPS II, SOFA, the efficacy of the prognosis of mortality given by each scale and the results were compared between the three scales. Statistical analysis was performed by descriptive statistical mean, frequencies, measures of central tendency, frequencies for qualitative variables. Statistics nonparametric with χ2 for bivariate analysis, correlation test of Kendall and linear regression, plotting with ROC curve. Results: 244 records of patients admitted to the ICU were analyzed, the following data were found 174 survivors and 70 deaths for a 28.7% mortality; with a mean age of 44.64 SD ± 17.9; by gender 134 of female and 110 male; being the main cause of admission to patients postsurgical 73 (29.9%) and patients with sepsis or septic shock 54 (22.1%); in regarding the scales, you predict the correlation APACHE II-SAPS II 0.784, APACHE II vs SOFA 0.761, SOFA vs SAPS II 0.723. and in SOFA linear regression with a coefficient of B 0.208 and β 0.642. Conclusion: There is a correlation between higher real mortality as increases the score with respect to the APACHE scale and SAPS II. Performing the linear regression we can say that SOFA has greater susceptibility to the other APACHE II and SAPS II prognostic scales. With a 95% CI.

Resumo: Introdução: A unidade de terapia intensiva (UTI) é a área hospitalar na qual é responsável pela assistência médica integral de pacientes criticamente enfermos com grandes chances de recuperação; as escalas de prognóstico de mortalidade funcionam como indicadores objetivos e padronizados para a categorização dos pacientes em termos de gravidade desta forma padronizar sua admissão nestas unidades, bem como avaliar a eficácia e qualidade do nosso trabalho como médicos nessas UTIs. Objetivo: Determinar qual é a escala prognóstica de mortalidade mais eficaz para UTI do HGR No. 20. Material e métodos: Foi realizado um estudo descritivo, transversal, retrospectivo, comparativo na UTI do HGR No. 20, no período de 1o de Janeiro de 2016 a 31 de dezembro de 2016. Aplicou-se três escalas de prognóstico de mortalidade APACHEII, SAPS II, SOFA, determinou-se a efetividade do prognóstico de mortalidade dada por cada escala e os resultados foram comparados entre as três escalas. A análise estatística foi realizada por estatística descritiva média, frequências, medidas de tendência central, frequências para variáveis qualitativas. Estatísticas não paramétrico com χ2 para análise bivariada, teste de correlação de Kendall e regressão linear, plotado com curva ROC. Resultados: Foram analisados 244 prontuários de pacientes internados na UTI, encontramos os seguintes dados: 174 sobreviventes e 70 óbitos para uma mortalidade de 28.7%; com idade média de 44.64 DP± 17.9; por gênero 134 de feminino e 110 masculino; sendo a principal causa de admissão de pacientes pós-operatório 73 (29.9%) e pacientes com sepse ou choque séptico 54 (22.1%); Em relação às escalas prognósticas, a correlação APACHE II- SAPSII 0.784, APACHEII vs SOFA 0.761, SOFA vs SAPS II 0.723 e na regressão linear SOFA com um coeficiente de B 0.208 e β 0.642. Conclusão: Existe uma correlação entre uma maior mortalidade real a medida que aumenta a pontuação em relação à escala APACHE e SAPS II. Realizando a regressão linear podemos dizer que o SOFA tem maior suscetibilidade a outras escalas de prognóstico APACHE II e SAPS II. Com um IC de 95%.

Aplicación de escalas pronósticas de gravedad en la neumonía por SARS-CoV-2 / Application of validated severity scores for pneumonia caused by SARS-CoV-2

Objetivos: Comparar el rendimiento de las escalas pronósticas PSI, CURB-65, MuLBSTA y COVID-GRAM para predecir mortalidad y necesidad de ventilación mecánica invasiva en pacientes con neumonía por SARS-CoV-2. Valorar la existencia de coinfección bacteriana respiratoria durante el ingreso.MétodoEstudio observacional retrospectivo que incluyó a adultos hospitalizados con neumonía por SARS-CoV-2 del 15 de marzo al 15 de mayo de 2020. Se excluyó a aquellos inmunodeprimidos, institucionalizados e ingresados en los 14 días previos por otro motivo. Se realizó un análisis de curvas ROC, calculando el área bajo la curva para las diferentes escalas, así como sensibilidad, especificidad y valores predictivos.ResultadosSe incluyó a 208 pacientes, con edad de 63±17 años; el 57,7% eran hombres. Ingresaron en UCI 38 (23,5%), de estos, 33 precisaron ventilación mecánica invasiva (86,8%), con una mortalidad global del 12,5%. Las áreas bajo las curvas ROC para mortalidad de los clasificaciones fueron: PSI 0,82 (IC 95%: 0,73-0,91); CURB-65 0,82 (0,73-0,91); MuLBSTA 0,72 (0,62-0,81) y COVID-GRAM 0,86 (0,70-1). Las áreas para necesidad de ventilación mecánica invasiva fueron: PSI 0,73 (IC 95%: 0,64-0,82); CURB-65 0,66 (0,55-0,77); MuLBSTA 0,78 (0,69-0,86) y COVID-GRAM 0,76 (0,67-0,85), respectivamente. Los pacientes que presentaron coinfección bacteriana respiratoria fueron 20 (9,6%); los gérmenes más frecuentes fueron Pseudomonas aeruginosa y Klebsiella pneumoniae.ConclusionesEn nuestro estudio la escala COVID-GRAM fue la más precisa para identificar a los pacientes con mayor mortalidad ingresados con neumonía por SARS-CoV-2; no obstante, ninguna de estas escalas predice de forma precisa la necesidad de ventilación mecánica invasiva con ingreso en UCI. El 10% de los pacientes presentó coinfección bacteriana respiratoria.

Objectives: Compare the accuracy of PSI, CURB-65, MuLBSTA and COVID-GRAM prognostic scores to predict mortality, the need for invasive mechanical ventilation in patients with pneumonia caused by SARS-CoV-2 and assess the coexistence of bacterial respiratory tract infection during admission.MethodsRetrospective observational study that included hospitalized adults with pneumonia caused by SARS-CoV-2 from 15/03 to 15/05/2020. We excluded immunocompromised patients, nursing home residents and those admitted in the previous 14 days for another reasons. Analysis of ROC curves was performed, calculating the area under the curve for the different scales, as well as sensitivity, specificity and predictive values.ResultsA total of 208 patients were enrolled, aged 63±17 years, 57,7% were men; 38 patients were admitted to ICU (23,5%), of these patients 33 required invasive mechanical ventilation (86,8%), with an overall mortality of 12,5%. Area under the ROC curves for mortality of the scores were: PSI 0,82 (95% CI: 0,73-0,91), CURB-65 0,82 (0,73-0,91), MuLBSTA 0,72 (0,62-0,81) and COVID-GRAM 0,86 (0,70-1). Area under the curve for needing invasive mechanical ventilation was: PSI 0,73 (95% CI: 0,64-0,82), CURB-65 0,66 (0,55-0,77), MuLBSTA 0,78 (0,69-0,86) and COVID-GRAM 0,76 (0,67-0,85), respectively. Patients with bacterial co-infections of the respiratory tract were 20 (9,6%), the most frequent strains being Pseudomonas aeruginosa and Klebsiella pneumoniae.ConclusionsIn our study, the COVID-GRAM score was the most accurate to identify patients with higher mortality with pneumonia caused by SARS-CoV-2; however, none of these scores accurately predicts the need for invasive mechanical ventilation with ICU admission. The 10% of patients admitted presented bacterial respiratory co-infection. (AU)

Comparación de 4 escalas pronósticas para predecir mortalidad en pacientes con morbilidad materna severa / Comparison of four prognostic scales for predicting mortality in patients with severe maternal morbidity

Objetivo Comparar la validez pronóstica del APACHE II-M y O-SOFA versus el APACHE II y SOFA para predecir mortalidad en pacientes con morbilidad materna severa. Diseño Estudio de cohorte, retrospectivo, longitudinal y analítico. Ámbito Unidad de cuidados intensivos (UCI) médico-quirúrgica de un hospital de tercer nivel. Pacientes Pacientes embarazadas o puérperas de cualquier edad ingresadas en la UCI. Intervenciones Cálculo de scores pronósticos al ingreso. Variables de interés APACHE II, SOFA, APACHE II-M, O-SOFA y mortalidad materna. Resultados Se incluyeron 141 pacientes. Noventa y nueve (70,2%) fueron puérperas. El diagnóstico más frecuente fue la enfermedad hipertensiva del embarazo (50 casos). La discriminación de cada modelo pronóstico se estimó con el área bajo la curva ROC (ABC-ROC). La calibración se estimó utilizando la razón de mortalidad y el estadístico de Hosmer-Lemeshow. Las 4 escalas discriminaron entre supervivientes y no supervivientes con áreas bajo la curva >0,85. El modelo APACHE II-M fue el modelo pronóstico con mayor discriminación y calibración. En la regresión de Hosmer-Lemeshow la predicción de mortalidad de APACHE II y O-SOFA fue significativamente diferente a las muertes observadas. Conclusiones el APACHE II-M tuvo la mayor validez pronóstica para predecir muerte materna. Esta diferencia está dada por su mejoría en la calibración. (AU)

Objective To compare the prognostic validity of the APACHE II-M and O-SOFA scales versus the APACHE II and SOFA to predict mortality in patients with severe maternal morbidity. Design A retrospective, longitudinal and analytical cohort study was carried out. Setting Medical-surgical intensive care unit (ICU) of a tertiary hospital. Patients Pregnant or puerperal patients of any age admitted to the ICU. Interventions Calculation of prognostic scores upon admission. Variables of interest APACHE II, SOFA, APACHE II-M and O-SOFA scores and maternal mortality. Results A total of 141 patients were included. The majority (70.2%) were puerperal. The most frequent diagnosis was gestational hypertensive disease (50 cases). The discrimination of each prognostic model was estimated with the area under the ROC curve (AUC-ROC). The calibration was estimated using the mortality ratio and the Hosmer-Lemeshow statistic. The four scales discriminated between survivors and non-survivors with areas under the curve >0.85. The APACHE II-M model was the predictive model with the highest discrimination and calibration. In the Hosmer-Lemeshow regression analysis, mortality as predicted by the APACHE II and O-SOFA was significantly different from the observed mortality. Conclusions The APACHE II-M exhibited the greatest prognostic validity in predicting maternal mortality. This difference was given by its improvement in calibration. (AU)

[Application of validated severity scores for pneumonia caused by SARS-CoV-2]. / Aplicación de escalas pronósticas de gravedad en la neumonía por SARS-CoV-2.

OBJECTIVES: Compare the accuracy of PSI, CURB-65, MuLBSTA and COVID-GRAM prognostic scores to predict mortality, the need for invasive mechanical ventilation in patients with pneumonia caused by SARS-CoV-2 and assess the coexistence of bacterial respiratory tract infection during admission. METHODS: Retrospective observational study that included hospitalized adults with pneumonia caused by SARS-CoV-2 from 15/03 to 15/05/2020. We excluded immunocompromised patients, nursing home residents and those admitted in the previous 14 days for another reasons. Analysis of ROC curves was performed, calculating the area under the curve for the different scales, as well as sensitivity, specificity and predictive values. RESULTS: A total of 208 patients were enrolled, aged 63±17 years, 57,7% were men; 38 patients were admitted to ICU (23,5%), of these patients 33 required invasive mechanical ventilation (86,8%), with an overall mortality of 12,5%. Area under the ROC curves for mortality of the scores were: PSI 0,82 (95% CI: 0,73-0,91), CURB-65 0,82 (0,73-0,91), MuLBSTA 0,72 (0,62-0,81) and COVID-GRAM 0,86 (0,70-1). Area under the curve for needing invasive mechanical ventilation was: PSI 0,73 (95% CI: 0,64-0,82), CURB-65 0,66 (0,55-0,77), MuLBSTA 0,78 (0,69-0,86) and COVID-GRAM 0,76 (0,67-0,85), respectively. Patients with bacterial co-infections of the respiratory tract were 20 (9,6%), the most frequent strains being Pseudomonas aeruginosa and Klebsiella pneumoniae. CONCLUSIONS: In our study, the COVID-GRAM score was the most accurate to identify patients with higher mortality with pneumonia caused by SARS-CoV-2; however, none of these scores accurately predicts the need for invasive mechanical ventilation with ICU admission. The 10% of patients admitted presented bacterial respiratory co-infection.

Comparison of four prognostic scales for predicting mortality in patients with severe maternal morbidity. / Comparación de 4 escalas pronósticas para predecir mortalidad en pacientes con morbilidad materna severa.

OBJECTIVE: To compare the prognostic validity of the APACHE II-M and O-SOFA scales versus the APACHE II and SOFA to predict mortality in patients with severe maternal morbidity. DESIGN: A retrospective, longitudinal and analytical cohort study was carried out. SETTING: Medical-surgical intensive care unit (ICU) of a tertiary hospital. PATIENTS: Pregnant or puerperal patients of any age admitted to the ICU. INTERVENTIONS: Calculation of prognostic scores upon admission. VARIABLES OF INTEREST: APACHE II, SOFA, APACHE II-M and O-SOFA scores and maternal mortality. RESULTS: A total of 141 patients were included. The majority (70.2%) were puerperal. The most frequent diagnosis was gestational hypertensive disease (50 cases). The discrimination of each prognostic model was estimated with the area under the ROC curve (AUC-ROC). The calibration was estimated using the mortality ratio and the Hosmer-Lemeshow statistic. The four scales discriminated between survivors and non-survivors with areas under the curve >0.85. The APACHE II-M model was the predictive model with the highest discrimination and calibration. In the Hosmer-Lemeshow regression analysis, mortality as predicted by the APACHE II and O-SOFA was significantly different from the observed mortality. CONCLUSIONS: The APACHE II-M exhibited the greatest prognostic validity in predicting maternal mortality. This difference was given by its improvement in calibration.

Diseño y validación de la escala pronóstica cubana PREDICMED para estratificar el riesgo de mediastinitis postoperatoria / Design and validation of the Cuban prognostic scale PREDICMED to stratify the risk of postoperative mediastinitis

RESUMEN Introducción: La predicción de fenómenos en las ciencias médicas mediante escalas pronósticas constituye una herramienta valiosa en la actualidad y deben incluirse en el proceso de toma de decisiones. Pronosticar la mediastinitis postoperatoria permite disponer de recursos para su prevención. Objetivo: Construir una escala pronóstica para estratificar el riesgo de padecer mediastinitis postoperatoria. Método: Se realizó un estudio de casos y controles para los factores de riesgo de mediastinitis postoperatoria en el Cardiocentro Ernesto Guevara de Santa Clara, Cuba. Luego de la regresión logística se obtuvo el modelo y, a partir de este, se incluyeron y ponderaron los predictores para obtener la escala cubana pronóstica de mediastinitis postoperatoria: PREDICMED, que se validó por diversos métodos. Resultados: Esta escala se obtuvo con seis predictores y dos estratos de riesgo. Se analizó su rendimiento mediante ajuste, calibración y determinación de su poder discriminante, con buenos resultados. Se realizó validación interna por el método de división de datos y se comparó su capacidad en ambos subconjuntos (desarrollo y validación) sin diferencias. Se probó su buena validez de constructo, al no existir diferencias entre las probabilidades predichas y las observadas. También se analizó su validez de contenido mediante expertos. Por último, se determinó su validez de criterio al comparar con otra escala similar (MEDSCORE). PREDICMED presentó muy buena capacidad discriminatoria (área bajo la curva 0,962) y elevados valores de sensibilidad (84,62%) y especificidad (92,31%). Conclusiones: La escala pronóstica cubana PREDICMED, para estratificar el riesgo de mediastinitis postoperatoria, mostró buenos parámetros de validación y logró estratificar el riesgo en no alto y alto.

ABSTRACT Introduction: Phenomena prediction through prognostic scales is a valuable tool in medical sciences nowadays and it should be included in the decision-making process. Predicting postoperative mediastinitis allows to count on resources for its prevention. Objective: To build a prognostic scale to stratify the risk of suffering from postoperative mediastinitis. Method: A case-control study for the risk factors of postoperative mediastinitis was carried out at the Cardiocentro Ernesto Guevara from Santa Clara, Cuba. After the logistic regression, the model was obtained and from it, the predictors to obtain the Cuban prognostic scale of postoperative mediastinitis PREDICMED were included and weighted, which was validated through several methods. Results: This scale was obtained, counting on six predictors and two risk strata. Its performance was analyzed through adjustment, calibration and determination of its discriminating capacity, showing good results. Internal validation was carried out through the data division method and its capacity was compared in both subsets (development and validation) showing no differences. Its good construct validity was demonstrated, since there were no differences between the predicted and the observed probabilities. Its contents validity was also analyzed by experts. Finally, its criteria validity was determined when compared with another similar scale (Medscore). PREDICMED showed a very good discriminatory capacity (area under the curve 0.962) as well as high values of sensitivity (84.62%) and specificity (92.31%). Conclusions: The Cuban prognostic scale PREDICMED, to stratify the risk of postoperative mediastinitis showed good validation parameters and it was able to stratify the risk in not high and high.

Utilidad de las escalas Rockall y Baylor modificado en hemorragia digestiva alta por úlcera péptica / Usefulness of the Modified Rockall and Baylor Scores in Gastrointestinal Hemorrhage due to Peptic Ulcer

Introducción: la hemorragia digestiva alta constituye un problema de salud frecuente en todo el mundo y es una de las urgencias que determina gran número de ingresos en los servicios de Cirugía General en nuestro medio, por lo que reviste gran importancia clínica y sanitaria. Objetivo: determinar la utilidad de las escalas de Rockall y Baylor modificado para pronosticar resangrado en pacientes con hemorragia digestiva alta. Método: se realizó un estudio observacional descriptivo prospectivo, incluyendo a los pacientes ingresados por hemorragia digestiva alta por úlcera péptica en el Hospital Enrique Cabrera, desde el 1ro. de enero del 2012 hasta el 30 de septiembre del 2015. Resultados: de 300 pacientes ingresados por hemorragia digestiva alta por úlcera péptica, se tomó una muestra de 71 enfermos. El tratamiento endoscópico se realizó a todos los pacientes, y el tratamiento quirúrgico en 8,4 por ciento. Nueve pacientes presentaron resangrado (12,7 por ciento). Las escalas de Rockall y Baylor modificado presentaron una especificidad de 82 por ciento y 86 por ciento, respectivamente con baja sensibilidad en ambos casos a pesar de esto la escala de Rockall es la de mayor sensibilidad. Conclusiones: las dos escalas fueron altamente específicas, pero la de Rockall fue más sensible para identificar los pacientes con riesgo alto de resangrado(AU)

Introduction: Upper gastrointestinal hemorrhage is a common health problem worldwide and one of the emergencies determining a huge number of admissions into general surgery services in our scenario, it is therefore of great clinical and sanitary importance. Objective: To determine the usefulness of the modified Rockall and Baylor scores in predicting rebleeding in patients with upper gastrointestinal hemorrhage. Method: A prospective, descriptive, observational study was carried out, including patients admitted for upper gastrointestinal hemorrhage due to peptic ulcer in Enrique Cabrera, from January 1st, 2015 to September 30, 2015. Results: Among the 300 patients admitted for upper digestive hemorrhage due to peptic ulcer, we took a sample of 71 patients. All patients were performed endoscopic treatment, while 8.4 percent were performed surgical treatment. Nine patients presented with rebleeding (12.7 percent). The modified Rockall and Baylor scores showed a specificity of 82 percent and 86 percent, respectively, with low sensitivity in both cases. Despite this, the Rockall score is the one with the highest sensitivity. Conclusions: The two score were highly specific, but the Rockall score was more sensitive for identifying patients at high risk of rebleeding(AU)

Utilidad de las escalas Rockall y Baylor modificado en hemorragia digestiva alta por úlcera péptica / Usefulness of the Modified Rockall and Baylor Scores in Gastrointestinal Hemorrhage due to Peptic Ulcer

Introducción: la hemorragia digestiva alta constituye un problema de salud frecuente en todo el mundo y es una de las urgencias que determina gran número de ingresos en los servicios de Cirugía General en nuestro medio, por lo que reviste gran importancia clínica y sanitaria. Objetivo: determinar la utilidad de las escalas de Rockall y Baylor modificado para pronosticar resangrado en pacientes con hemorragia digestiva alta. Método: se realizó un estudio observacional descriptivo prospectivo, incluyendo a los pacientes ingresados por hemorragia digestiva alta por úlcera péptica en el Hospital Enrique Cabrera, desde el 1ro. de enero del 2012 hasta el 30 de septiembre del 2015. Resultados: de 300 pacientes ingresados por hemorragia digestiva alta por úlcera péptica, se tomó una muestra de 71 enfermos. El tratamiento endoscópico se realizó a todos los pacientes, y el tratamiento quirúrgico en 8,4 por ciento. Nueve pacientes presentaron resangrado (12,7 por ciento). Las escalas de Rockall y Baylor modificado presentaron una especificidad de 82 por ciento y 86 por ciento, respectivamente con baja sensibilidad en ambos casos a pesar de esto la escala de Rockall es la de mayor sensibilidad. Conclusiones: las dos escalas fueron altamente específicas, pero la de Rockall fue más sensible para identificar los pacientes con riesgo alto de resangrado(AU)

Introduction: Upper gastrointestinal hemorrhage is a common health problem worldwide and one of the emergencies determining a huge number of admissions into general surgery services in our scenario, it is therefore of great clinical and sanitary importance. Objective: To determine the usefulness of the modified Rockall and Baylor scores in predicting rebleeding in patients with upper gastrointestinal hemorrhage. Method: A prospective, descriptive, observational study was carried out, including patients admitted for upper gastrointestinal hemorrhage due to peptic ulcer in Enrique Cabrera, from January 1st, 2015 to September 30, 2015. Results: Among the 300 patients admitted for upper digestive hemorrhage due to peptic ulcer, we took a sample of 71 patients. All patients were performed endoscopic treatment, while 8.4 percent were performed surgical treatment. Nine patients presented with rebleeding (12.7 percent). The modified Rockall and Baylor scores showed a specificity of 82 percent and 86 percent, respectively, with low sensitivity in both cases. Despite this, the Rockall score is the one with the highest sensitivity. Conclusions: The two score were highly specific, but the Rockall score was more sensitive for identifying patients at high risk of rebleeding(AU)

Clinical gestalt versus prognostic scores for prognostication of patients with acute symptomatic pulmonary embolism. / Evaluación clínica frente a escalas estandarizadas para el pronóstico de los pacientes con tromboembolia pulmonar aguda sintomática.

BACKGROUND AND OBJECTIVE: To determine the accuracy of clinical gestalt to identify patients with acute symptomatic pulmonary embolism (PE) at low-risk for short-term complications. PATIENTS AND METHODS: This study included a total of 154 consecutive patients diagnosed with acute symptomatic PE in a tertiary university hospital. We compared the prognostic accuracy of the Pulmonary Embolism Severity Index (PESI), the simplified PESI (sPESI), and clinical gestalt of 1) 2senior physicians (one with and one without experience in the management of patients with PE), 2) a fourth-year resident of Pneumology, 3) a third-year resident of Pneumology, and 4) a second-year resident of Pneumology. The primary outcome was all-cause mortality during the first month after the diagnosis of PE. RESULTS: Thirty-day all-cause mortality was 8.4% (13/154; 8.4%; 95% confidence interval [CI], 4.1-12.8%). The PESI and clinical gestalt classified more patients as low-risk, compared to the sPESI (36.4%, 31.3% y 28.6%, respectively). There were no deaths in the sPESI low-risk category (negative predictive value 100%). Prognostic accuracy increased with increasing experience (84.6 vs. 92.3%; P=.049). CONCLUSIONS: The sPESI showed the best accuracy at correctly identifying low-risk patients with acute symptomatic PE. Clinical gestalt is not inferior to standardized clinical prediction rules to prognosticate patients with acute PE.

Caracterización de escalas pronósticas del tromboembolismo pulmonar y cumplimiento de su profilaxis en pacientes de Mayabeque / Characterization of prognostic scales of pulmonary thromboembolism and fulfillment of its prophylaxis in patients from Mayabeque

Fundamento: existen diferentes escalas para el diagnóstico y pronóstico del tromboembolismo pulmonar. Los scores más utilizados para su predicción clínica son el de Well y el de Ginebra. Existe también el índice de sensibilidad para embolia pulmonar (PESI), considerada de gran utilidad y de mayor simplicidad. Objetivo: caracterizar y comparar escalas pronósticas del tromboembolismo pulmonar y el cumplimiento de su profilaxis en fallecidos por esta entidad, procedentes de los servicios quirúrgicos del hospital Aleida Fernández Chardiet, Mayabeque, en el periodo enero 2011 a diciembre 2016. Métodos: se realizó un estudio observacional descriptivo longitudinal y retrospectivo. El universo de estudio estuvo constituido por todos los pacientes fallecidos por tromboembolismo pulmonar de los servicios quirúrgicos del mencionado hospital, 31 pacientes en el período de tiempo declarado. La muestra quedó conformada por 14 pacientes, atendidos en cualquiera de los servicios quirúrgicos, mayores de 18 años de edad, con los datos necesarios en las historias clínicas y con confirmación diagnóstica de tromboembolismo pulmonar por necropsia. Resultados: según el test de Well y la escala de PESI, los pacientes presentaban alto riesgo de desarrollo del tromboembolismo pulmonar. El test de Ginebra no mostró predominio de alto riesgo. En la profilaxis del tromboembolismo pulmonar solo se cumplió un adecuado aporte de líquidos. Conclusiones: se evidenció la utilidad y el valor pronóstico del test de Wells y la escala de PESI como predictores al desarrollo de un tromboembolismo pulmonar. La profilaxis al mismo no fue adecuad (AU)

Background: there are different scales for the diagnosis and prognosis of pulmonary thromboembolism. The Geneva and the Wells scores are the most used clinical prediction rules. The index of sensitivity for pulmonary embolism (PE) also exists, and it is considered be very useful and simple. Objective: to describe and compare the prognostic scales for pulmonary thromboembolism and the performance of their prophylaxis, in the deceased due to this entity, from the surgical service of the Aleida Fernández Chardiet Hospital, from January 2011 to December 2016. Methods: a longitudinal and retrospective descriptive observational study was carried out. The universe was made up of all the patients, 31, who died of thromboembolism at the surgical service of the aforementioned hospital and during the period herein declared. The sample included 14 patients, attended to at any surgical services, over 18 years of age, with the necessary data in their medical records and with a confirmed diagnosis of pulmonary thromboembolism caused by necropsy.Results: according to the Wells rule and the PE scale, the patients presented a high risk for developing pulmonary thromboembolism. The Geneva test did not show prevalence of high risk. In the prophylaxis of pulmonary thromboembolism only an appropriate contribution of liquids was completed. Conclusions: the study showed the prognostic usefulness and value of the Wells score and the PE scale as predictors for the progress of pulmonary thromboembolism. Its prophylaxis was not appropriate(AU)

Assessment of Euroscore and SAPS III as hospital mortality predicted in cardiac surgery. / Valoración del Euroscore y SAPS III como predictor de mortalidad hospitalaria en el postoperatorio de cirugía cardiaca.

OBJECTIVES: To perform an external validation of Euroscore I, Euroscore II and SAPS III. PATIENTS AND METHOD: Retrospective cohort study over three years on all adult patients who underwent cardiac surgery. We reviewed the clinical data, following the patient until outcome or discharge from hospital (dead, alive). We computed the predicted mortality by Euroscore I (EI), II (EII) and SAPS III. The model validation was assessed by discrimination: area under curve ROC; and calibration (Hosmer-Lemeshow test). RESULTS: 866 patients were included. 62.5% of them male, with a median age of 69 years, 6.1% died during hospitalization. Predicted mortality: E I 7.94%, E II 3.54, SAPS III 12.1%. Area under curve (95% IC): E I 0.862 (0.812-0.912); E II 0.861 (0.806-0.915); SAPS III 0.692 (0.601-0.784). Hosmer-Lemeshow test: E I 14.0046 (P=.08164); E II 33.67 (P=.00004660); SAPS III 11.57 (P=.171). CONCLUSIONS: EII had good discrimination, but the calibration was not good with predicted mortality lower than the real mortality. E I showed the best discrimination with good calibration and a tendency to overestimate the mortality. SAPS III showed poor discrimination with good calibration and a tendency to greatly overestimate the predicted mortality. We saw no improvement in the predictive performance of EII over I and we reject the use of SAPS III in this kind of patient.

Alteraciones electrocardiográficas en pacientes con hemorragia intracerebral espontánea / Electrocardiographic changes in patients with spontaneous intracerebral hemorrhage

Introducción: desde la última centuria se estudia la asociación entre eventos cerebrovasculares hemorrágicos y alteraciones electrocardiográficas, así como el valor de estas como factor pronóstico de mortalidad. Objetivo: caracterizar las alteraciones electrocardiográficas en pacientes con hemorragia intracerebral espontánea a su llegada al Servicio de Urgencias. Material y Método: se realizó un estudio observacional descriptivo de corte transversal de las alteraciones electrocardiográficas agudas en pacientes con hemorragia cerebral durante el período de enero del 2010 hasta diciembre del 2011 en el Hospital Comandante Manuel Fajardo de La Habana. Resultados: se observó un predominio del sexo femenino y la media de edad fue de 70 años, las alteraciones electrocardiográficas más frecuentes fueron la taquicardia sinusal, el aplanamiento o inversión de la onda T y la bradicardia sinusal. Las dos terceras partes de los pacientes que presentaron dichas alteraciones fallecieron. Conclusiones: cerca de 50 por ciento de los pacientes presentó cambios electrocardiográficos. Estos predominaron en pacientes femeninos, y se observó una relación estadísticamente significativa con los egresados fallecidos(AU)

Introduction: for the last hundred years the relationship between hemorrhagic cerebrovascular events and electrocardiographic alterations has been studied, as well as their significance as a prognostic factor for mortality. Objective: to characterize the electrocardiographic alterations in patients with spontaneous intracerebral hemorrhage at their arrival to the Emergency Room. Material and Method: an observational descriptive and transverse study was carried out between January 2010 and December 2011 in Comandante Manuel Fajardo University Hospital. Results: it was found a predominance of females, with an average age of 70 years. The most frequent electrocardiographic alterations were sinus tachycardia, sinus bradycardia, and flat or inverted T waves. Around two thirds of the patients with these changes died in the hospital. Conclusions: nearly 50 percent of patients presented with electrocardiographic anomalies on admittance. They prevailed in female patients and a statistically significant difference was found between them and adverse outcomes(AU)

Predictive scoring systems in multiorgan failure: A cohort study.

OBJECTIVE: An evaluation is made of the hospital mortality predicting capacity of the main predictive scoring systems. DESIGN: A 2-year retrospective cohort study was carried out. SETTING: A third level ICU with surgical and medical patients. PATIENTS: All patients with multiorgan failure during the first day in the ICU. MAIN VARIABLES: APACHE II and IV, SAPS II and III, MPM II and hospital mortality. RESULTS: A total of 568 patients were included. Mortality rate: 39.8% (226 patients). Discrimination (area under the ROC curve; 95% CI): APACHE IV (0.805; 0.751-0.858), SAPS II (0.755; 0.697-0.814), MPM II (0.748; 0.688-0.809), SAPS III (0.737; 0.675-0.799) and APACHE II (0.699; 0.633-0.765). MPM II showed the best calibration, followed by SAPS III. APACHE II, SAPS II and APACHE IV showed very poor calibration. Standard mortality ratio (95% CI): APACHE IV 1.9 (1.78-2.02); APACHE II 1.1 (1.07-1.13); SAPS III 1.1 (1.06-1.14); SAPS II 1.03 (1.01-1.05); MPM 0.9 (0.86-0.94). CONCLUSIONS: APACHE IV showed the best discrimination, with poor calibration. MPM II showed good discrimination and the best calibration. SAPS II, in turn, showed the second best discrimination, with poor calibration. The APACHE II calibration and discrimination values currently disadvise its use. SAPS III showed good calibration with modest discrimination. Future studies at regional or national level and in certain critically ill populations are needed.

[Pulmonary embolism in patients with cancer: foundations of the EPIPHANY study]. / Embolia pulmonar en el paciente oncológico: bases para el estudio EPIPHANY.

Pulmonary thromboembolism (PE) is a common cause of morbidity and mortality in patients with cancer. Having cancer is an independent risk factor for death in the general series of patients with PE and is included as a variable in the prognostic scales of acute symptomatic PE. This fact limits the discriminatory power of these general scales for patients with cancer and has prompted the development of specific prognostic tools: POMPE-C and a scale derived from the RIETE registry. Whether the increased risk of death by PE in patients with cancer is due to complications related to the neoplasm or to a greater severity of the thromboembolic episode in this population has not been well studied. Moreover, the introduction of computed multidetector tomography in recent years has led to a growing diagnosis of incidental PE, which currently represents up to half of pulmonary embolisms in patients with cancer. The EPIPHANY study attempts to further the understanding of the characteristics of pulmonary embolisms in patients with cancer by including incidental and symptomatic events. Its primary objectives are a) to understand the clinical and epidemiological patterns of pulmonary embolism associated with cancer and b) to develop and validate a specific prognosis model for PE in this population. The registry includes variables of interest to oncology (cancer type and extent, oncospecific treatments, patient's functional condition, cancer progression), radiological variables (thrombotic burden, signs of ventricular overload and other findings), location of treatment (hospital or outpatient), acute complications and causes of death in patients with PE associated with cancer.

Escalas de predicción en el pronóstico del paciente con hemorragia digestiva alta no varicosa / Predicting scales for prognosis of patients with non-variceal upper gastrointestinal bleeding

La hemorragia digestiva alta no varicosa constituye una importante causa de morbilidad y mortalidad en el mundo. Para su manejo se ha impuesto la necesidad de usar escalas pronósticas para definir la conducta a seguir con un empleo óptimo de los recursos médicos, de manera tal que se garantice una asistencia de calidad al paciente. El objetivo del trabajo es realizar un resumen de los aspectos positivos y negativos de las escalas, relacionar los parámetros que contemplan y las posibilidades de su aplicación en Cuba. Se efectuó una búsqueda en los registros bibliográficos existentes de las bases de datos de PUBMED y EBSCO. Se utilizaron las palabras claves, en idiomas español e inglés: hemorragia digestiva alta no varicosa y escalas pronósticas. Se realizó una revisión de los diferentes modelos; se relacionaron a los autores principales de las escalas; se dividieron en preendoscópicas y endoscópicas y se caracterizaron las más utilizadas. La información recogida permitió obtener una visión general, al mostrar las diferentes variantes existentes y clasificar al paciente según el riesgo que presenta, de acuerdo con los índices pronósticos obtenidos después de la aplicación de la escala. Se concluye que las escalas pronósticas permiten evaluar la necesidad de intervención urgente, la probabilidad de sangrado, la necesidad de cirugía o la mortalidad aguda en la toma de decisiones médicas y su uso está en correspondencia con las particularidades de cada contexto.

The non-variceal upper gastrointestinal bleeding is a major cause of morbidity and mortality worldwide. The need for prognostic scales to define the course of action regarding the optimal use of medical resources has imposed, so that patient care quality is guaranteed. The aim of this paper is to go over the positive and negative aspects of the scales, to relate the parameters included and the possibilities of its application in Cuba. A search was conducted on existing bibliographic records in PubMed and EBSCO databases. Keywords in Spanish and English were used, such as non-variceal upper gastrointestinal bleeding, and prognostic scales. A review of different models was performed; the principal authors of the scales were related; scales were divided into pre-endoscopic and endoscopic and the most used were characterized. The information collected allowed for an overview, showing the various existing variants and classify patients according to risks, according to forecasts indices obtained after the scale application. It is concluded that the prognostic scales to assess the need for urgent intervention, the bleeding likelihood, surgery or acute mortality in medical decision making and their use is in line with each context particularities.

Escalas de predicción en el pronóstico del paciente con hemorragia digestiva alta no varicosa / Predicting scales for prognosis of patients with non-variceal upper gastrointestinal bleeding

La hemorragia digestiva alta no varicosa constituye una importante causa de morbilidad y mortalidad en el mundo. Para su manejo se ha impuesto la necesidad de usar escalas pronósticas para definir la conducta a seguir con un empleo óptimo de los recursos médicos, de manera tal que se garantice una asistencia de calidad al paciente. El objetivo del trabajo es realizar un resumen de los aspectos positivos y negativos de las escalas, relacionar los parámetros que contemplan y las posibilidades de su aplicación en Cuba. Se efectuó una búsqueda en los registros bibliográficos existentes de las bases de datos de PUBMED y EBSCO. Se utilizaron las palabras claves, en idiomas español e inglés: hemorragia digestiva alta no varicosa y escalas pronósticas. Se realizó una revisión de los diferentes modelos; se relacionaron a los autores principales de las escalas; se dividieron en preendoscópicas y endoscópicas y se caracterizaron las más utilizadas. La información recogida permitió obtener una visión general, al mostrar las diferentes variantes existentes y clasificar al paciente según el riesgo que presenta, de acuerdo con los índices pronósticos obtenidos después de la aplicación de la escala. Se concluye que las escalas pronósticas permiten evaluar la necesidad de intervención urgente, la probabilidad de sangrado, la necesidad de cirugía o la mortalidad aguda en la toma de decisiones médicas y su uso está en correspondencia con las particularidades de cada contexto(AU)

The non-variceal upper gastrointestinal bleeding is a major cause of morbidity and mortality worldwide. The need for prognostic scales to define the course of action regarding the optimal use of medical resources has imposed, so that patient care quality is guaranteed. The aim of this paper is to go over the positive and negative aspects of the scales, to relate the parameters included and the possibilities of its application in Cuba. A search was conducted on existing bibliographic records in PubMed and EBSCO databases. Keywords in Spanish and English were used, such as non-variceal upper gastrointestinal bleeding, and prognostic scales. A review of different models was performed; the principal authors of the scales were related; scales were divided into pre-endoscopic and endoscopic and the most used were characterized. The information collected allowed for an overview, showing the various existing variants and classify patients according to risks, according to forecasts indices obtained after the scale application. It is concluded that the prognostic scales to assess the need for urgent intervention, the bleeding likelihood, surgery or acute mortality in medical decision making and their use is in line with each context particularities(AU)

Utilidad de la escala pronóstica SWIFT en una Unidad de Cuidados Intensivos Polivalente / Utility of the SWIFT prognostic scale at a Polyvalent Intensive Care Unit

Introducción: el SWIFT es un índice creado para predecir eventos adversos reingresos y mortalidad oculta tras el alta de la Unidad de Cuidados Intensivos. Objetivo: evaluar la utilidad de la escala pronóstica SWIFT en la predicción de eventos adversos tras el alta de la unidad. Métodos: se realizó un estudio de cohorte en la Unidad de Cuidados Intensivos polivalente 8B del Hospital Clínico Quirúrgico Hermanos Ameijeiras, de provincia La Habana, en el periodo comprendido desde el 1ro de marzo de 2009 hasta el 28 de febrero de 2011. Los pacientes fueron divididos en dos grupos según el resultado de la escala: < 15 puntos y otro con ≥ 15, evaluándose la ocurrencia de mortalidad oculta y reingresos. Como variables principales se midieron: la mortalidad, los eventos adversos, la puntuación de la escala SAPS- 3 y la comparación de ésta con la escala SWIFT. Resultados: La escala SWIFT resultó ser útil en la predicción de eventos adversos tras el alta de UCI sin discriminar en el tiempo. La mayor puntuación de SAPS-3 al ingreso se correspondió con un mayor valor del Índice de SWIFT al egreso de la Unidad de Cuidados Intensivos.Conclusiones: los pacientes egresados de la Unidad de Cuidados Intensivos con una puntuación SWIFT ≥15 puntos presentaron una estadía discretamente superior aquellos con SWIFT‹15 puntos no teniendo relevancia estadística (AU)

Introduction: SWIFT is an index created to predict adverse events (readmissions and hidden mortality) after discharge from the ICU.Objective: to evaluate the usefulness of the SWIFT prognostic scale in predicting adverse events after unit discharge.Methods: It was conducted a cohort study in Unit 8B Polyvalent Intensive Care Unit of Hermanos Ameijeiras Clinical Surgical Hospital, of Havana province, in the period from March 1st, 2009 until February 28, 2011. The patients were divided into two groups according to the result of the scale: <15 points and another with ≥ 15, evaluating the occurrence of hidden mortality and readmissions. As main variables it was measured: mortality, adverse events, the SAPS- 3 scale score and its comparison with the SWIFT scale.Results: the SWIFT scale proved to be useful in predicting adverse events after discharge from the ICU without discriminating over time. The highest SAPS-3 score on admission corresponded to a higher value of the SWIFT Index at discharge from Intensive Care Unit.Conclusions: patients discharged from the ICU with a SWIFT score ≥ 15 points presented a slightly higher stay than those with SWIFT <15 points having no statistical significance.

Adaptation of the Palliative Prognostic Index in patients with advanced medical conditions.

OBJECTIVE: To analyze the accuracy of the Palliative Prognostic Index (PPI) in patients with advanced medical diseases and to recalibrate it in order to adapt it to the profile of these patients. METHODS: Multicenter, prospective, observational study that included patients with one or more advanced medical diseases. Calibration (Hosmer-Lemeshow goodness of fit) and discriminative power (ROC and area under the curve [AUC]) of PPI were analyzed in the prediction of mortality at 180 days. Recalibration was carried out by analyzing the scores on the PPI of each quartile upward of dying probability. Accuracy of PPI was compared with that obtained for the Charlson index. RESULTS: Overall mortality of the 1.788 patients was 37.5%. Calibration in the prediction of mortality was good (goodness of fit with P=.21), the prognostic probabilities ranging from 0-0,25 in the first quartile of risk and from 0,48-0,8 in the last quartile. Discriminative power was acceptable (AUC=69; P=.0001). In recalibrated groups, mortality of patients with 0/1-2/2.5-9.5/≥10 points was 13, 23, 39 and 68%, respectively. Sensitivity (S) and negative predicative value (NPF) of the cutoff point above 0 points were 96 and 87%, respectively; while specificity (sp) and positive predictive value (PPV) of the cutoff point above 9.5 points were 95 and 68%. Calibration of the Charlson index was good (P=.2), and its discriminative power (AUC=.52; P=.06) was suboptimal. CONCLUSIONS: PPI can be a useful tool in predicting 6-month survival of patients with advanced medical conditions.

Utilidad de la escala pronóstica SWIFT en una Unidad de Cuidados Intensivos Polivalente / Utility of the SWIFT prognostic scale at a Polyvalent Intensive Care Unit

Introducción: el SWIFT es un índice creado para predecir eventos adversos reingresos y mortalidad oculta tras el alta de la Unidad de Cuidados Intensivos. Objetivo: evaluar la utilidad de la escala pronóstica SWIFT en la predicción de eventos adversos tras el alta de la unidad. Métodos: se realizó un estudio de cohorte en la Unidad de Cuidados Intensivos polivalente 8B del Hospital Clínico Quirúrgico Hermanos Ameijeiras, de provincia La Habana, en el periodo comprendido desde el 1ro de marzo de 2009 hasta el 28 de febrero de 2011. Los pacientes fueron divididos en dos grupos según el resultado de la escala: < 15 puntos y otro con ≥ 15, evaluándose la ocurrencia de mortalidad oculta y reingresos. Como variables principales se midieron: la mortalidad, los eventos adversos, la puntuación de la escala SAPS- 3 y la comparación de ésta con la escala SWIFT. Resultados: La escala SWIFT resultó ser útil en la predicción de eventos adversos tras el alta de UCI sin discriminar en el tiempo. La mayor puntuación de SAPS-3 al ingreso se correspondió con un mayor valor del Índice de SWIFT al egreso de la Unidad de Cuidados Intensivos.Conclusiones: los pacientes egresados de la Unidad de Cuidados Intensivos con una puntuación SWIFT ≥15 puntos presentaron una estadía discretamente superior aquellos con SWIFT‹15 puntos no teniendo relevancia estadística

Introduction: SWIFT is an index created to predict adverse events (readmissions and hidden mortality) after discharge from the ICU.Objective: to evaluate the usefulness of the SWIFT prognostic scale in predicting adverse events after unit discharge.Methods: It was conducted a cohort study in Unit 8B Polyvalent Intensive Care Unit of Hermanos Ameijeiras Clinical Surgical Hospital, of Havana province, in the period from March 1st, 2009 until February 28, 2011. The patients were divided into two groups according to the result of the scale: <15 points and another with ≥ 15, evaluating the occurrence of hidden mortality and readmissions. As main variables it was measured: mortality, adverse events, the SAPS- 3 scale score and its comparison with the SWIFT scale.Results: the SWIFT scale proved to be useful in predicting adverse events after discharge from the ICU without discriminating over time. The highest SAPS-3 score on admission corresponded to a higher value of the SWIFT Index at discharge from Intensive Care Unit.Conclusions: patients discharged from the ICU with a SWIFT score ≥ 15 points presented a slightly higher stay than those with SWIFT <15 points having no statistical significance.