Comparison of cervical, thoracic, and lumbar vertebral bone quality scores for increased utility of bone mineral density screening.

PURPOSE: To evaluate the associations among the validated lumbar vertebral bone quality (VBQ) score, and cervical and thoracic VBQ scores. METHODS: Radiographic records of 100 patients who underwent synchronous MRI of the cervical, thoracic, and lumbar spine were retrieved. DEXA-validated lumbar VBQ was calculated using median signal intensity (MSI) of the L1-L4 vertebrae and L3 CSF. VBQ was derived as the quotient of MSIL1-L4 divided by MSICSF. Cervical and thoracic VBQ were similarly obtained using C3-C6 and C5 CSF, and T5-T8 and T7 CSF, respectively. Paired sample t-tests were used to evaluate differences among regional VBQ scores. Independent sample t-tests were used to identify sex differences in VBQ. Regression models with one-way analysis of variance (ANOVA) were constructed to identify associations among all permutations of anthropometric and regional VBQ measures. RESULTS: Mean cervical, thoracic, and lumbar VBQ scores were 3.06 ± 0.89, 2.60 ± 0.77, and 2.47 ± 0.61, respectively. Mean differences of .127 (p = 0.045) and - 0.595 (p < 0.001) were observed between thoracic and lumbar, and cervical and lumbar VBQ scores. Correlations of 0.324, 0.356, and 0.600 (p < 0.001) were found between cervical and lumbar, cervical and thoracic, and thoracic and lumbar VBQ scores. Regression with ANOVA predicting lumbar VBQ in relation to cervical and thoracic VBQ demonstrated R Square values of 0.105 and 0.360 (p < 0.001), and ß coefficient values of 0.471 and 0.217 (p < 0.001), respectively. CONCLUSION: Thoracic VBQ provides values representative of the validated lumbar VBQ score. Cervical VBQ scores are distinct from lumbar VBQ scores and do not provide adequate surrogate values of lumbar VBQ.

Multiple sclerosis in Central America and Caribbean countries: frequency and clinical characterization of an emergent disease.

Background: Multiple Sclerosis (MS) is a common neurological disease among white populations of European origin. Frequencies among Latin Americans continue to be studied, however, epidemiologic, and clinical characterization studies lack from Central American and Caribbean countries. Ethnicity in these countries is uniformly similar with a prevalent Mestizo population. Methods and results: Data from January 2014 to December 2019 from Guatemala, El Salvador, Honduras, Nicaragua, Costa Rica, Panama, Dominican Republic, and Aruba on demographic, clinical, MRI and phenotypic traits were determined in coordinated studies: ENHANCE, a population-based, retrospective, observational study on incidence and clinical characteristics, and from the subgroup with MS national registries (Aruba, Dominican Republic, Honduras, and Panama), data on prevalence, phenotypes and demographics. Expanded Disability Status Scale (EDSS), and therapeutic schemes were included. ENHANCE data from 758 patients disclosed 79.8% of Mestizo ethnicity; 72.4% female; median age at onset 31.0 years and 33.2 at diagnosis. The highest incidence rate was from Aruba, 2.3-3.5 × 100,000 inhabitants, and the lowest, 0.07-0.15 × 100,000, from Honduras. Crude prevalence rates per 100,000 inhabitants fluctuated from 27.3 (Aruba) to 1.0 (Honduras). Relapsing MS accounted for 87.4% of cases; EDSS <3.0 determined in 66.6% (mean disease duration: 9.1 years, SD ± 5.0); CSF oligoclonal bands 85.7%, and 87% of subjects hydroxyvitamin D deficient. Common initial therapies were interferon and fingolimod. Switching from interferon to fingolimod was the most common escalation step. The COVID-19 pandemic affected follow-up aspects of these studies. Conclusion: This is the first study providing data on frequencies and clinical characteristics from 8 countries from the Central American and Caribbean region, addressing MS as an emergent epidemiologic disorder. More studies from these areas are encouraged.

Decreasing ICU and Hospital Length of Stay through a Standardized Respiratory Therapist-driven Electronic Clinical Care Pathway for Status Asthmaticus.

Introduction: Status asthmaticus (SA) is a cause of many pediatric hospitalizations. This study sought to evaluate how a standardized asthma care pathway (ACP) in the electronic medical record impacted the length of stay (LOS). Methods: An interdisciplinary team internally validated a standardized respiratory score for patients admitted with SA to a 25-bed pediatric intensive care unit (PICU) at a tertiary children's hospital. The respiratory score determined weaning schedules for albuterol and steroid therapies. In addition, pharmacy and information technology staff developed an electronic ACP within our electronic medical record system using best practice alerts. These best practice alerts informed staff to initiate the pathway, wean/escalate treatment, transition to oral steroids, transfer level of care, and complete discharge education. The PICU, stepdown ICU (SD ICU), and acute care units implemented the clinical pathway. Pre- and postintervention metrics were assessed using process control charts and compared using Welch's t tests with a significance level of 0.05. Results: Nine hundred two consecutive patients were analyzed (598 preintervention, 304 postintervention). Order set utilization significantly increased from 68% to 97% (P < 0.001), PICU LOS decreased from 38.4 to 31.1 hours (P = 0.013), and stepdown ICU LOS decreased from 25.7 to 20.9 hours (P = 0.01). Hospital LOS decreased from 59.5 to 50.7 hours (P = 0.003), with cost savings of $1,215,088 for the patient cohort. Conclusions: Implementing a standardized respiratory therapist-driven ACP for children with SA led to significantly increased order set utilization and decreased ICU and hospital LOS. Leveraging information technology and standardized pathways may improve care quality, outcomes, and costs for other common diagnoses.

Impacting Satisfaction, Learning, and Efficiency Through Structured Interdisciplinary Rounding in a Pediatric Intensive Care Unit: A Quality Improvement Project.

BACKGROUND: Daily rounds in many pediatric intensive care units (PICUs) vary in quality, duration, and participation. We hypothesized that implementing structured interdisciplinary bedside rounds (SIBR®) would improve our rounding process. METHODS: This was a quality improvement initiative in a 25-bed multidisciplinary PICU in a tertiary children's hospital. Baseline data included rounding duration; participation of nurses, respiratory care practitioners (RCP), parents; and physician order read-back practices. Interventions were implementing pre-rounding huddles, changing the start of the rounding week, and instituting a SIBR model. All staff, consecutive patients and parents participated over 18 months. We used Mann-Whitney, z-test, and t-tests for statistical analysis with a significance level of 0.05. We tracked data with a statistical process control chart. RESULTS: Rounds participation increased for nurses (88% to 100%), RCPs (13% to 61%), and families (24% to 49%) (all p <0.001). Physician order read-back increased (41% to 79%) (p<0.001). The median length of stay (LOS) decreased from 2.1 to 1.9 days (p=0.004) with no changes in mortality or readmissions. The proportion of top responses from family surveys increased from 0.69 to 0.76 (p<0.001). PICU rounding duration (minutes/patient) decreased from 17.1 to 11.3. Most resident physicians felt SIBR positively impacted their education (70%), was more effective than rounds without structure (97%), and that family presence positively impacted learning (70%). CONCLUSIONS: Implementing a SIBR process in our PICU resulted in greater family and staff satisfaction, improved workflow and decreased rounding time by 34% without compromising education. LOS decreased significantly with no increases in mortality or readmissions.

Genome-wide linkage analysis using cross-sectional and longitudinal traits for body mass index in a subsample of the Framingham Heart Study.

To evaluate linkage evidence for body mass index (BMI) using both cross-sectional and longitudinal data, we performed genome-wide multipoint linkage analyses on subjects who had complete data at four selected time points (initial, 8th, 12th, and 16th year following the initial visit) from the Framingham Heart Study. The cross-sectional measures included BMI at each of the four selected time points and the longitudinal measure was the within-subject mean of BMI at the above four time points. Using the variance components method, we consistently observed the maximum LOD score out of the genome scan using BMI at each time point and the mean of BMI between 049xd2 and GATA71H05 on chromosome 16. The highest LOD score (3.0) was at time point 1, while the lowest (1.9) was at time point 4. We also observed other suggestive linkages on chromosome 6, 10, and 18 at time point 1 only. The longitudinal measure we studied (mean of BMI) did not provide greater power to identify a positive linkage than some of the cross-sectional measures (e.g., time point 1). The changing of linkage evidence over time provided some insights on the variation of genetic effect on BMI with aging. There may be a QTL on chromosome 16 that contributes to BMI and this locus, and maybe others, is more likely to affect BMI during early adulthood.

Perfil clínico de pacientes tratados por meningitis tuberculosa en Hospital Nacional Rosales, enero 2014 a diciembre de 2018 / Clinical profile of patients treated for tuberculous meningitis at Hospital Nacional Rosales, January 2014 to December 2018

La tuberculosis (TB) se considera enfermedad endémica en El Salvador, una de las formas graves de presentación de la misma es la meningitis tuberculosa. El esquema nacional de vacunación del país cuenta con la administración del bacilo de Calmette-Guérin (BCG) para prevenir dicha forma grave de TB, a pesar de ello se siguen presentando casos severos con aparición de secuelas neurológicas e incluso la muerte. El tipo de estudio desarrollado es de carácter descriptivo, transversal y retrospectivo, para ello se incluyeron todos los pacientes que cumplieron los criterios de inclusión, siendo estos un total 51 casos. Se realizó revisión de expedientes clínicos empleando formulario de recolección de datos, los cuales fueron manejados únicamente por los integrantes del equipo a cargo de la investigación. Dado que la investigación implicó revisión de expedientes clínicos, se omitió el consentimiento informado, a su vez se respetaron los principios de buenas prácticas clínicas y de Helsinki. Los resultados revelan que la tuberculosis meníngea en El Hospital Nacional Rosales, tiene el mismo comportamiento que el descrito en la literatura internacional, siendo las características epidemiológicas, a predominio en sexo masculino, edad entre 21 y 40 años, procedencia del área urbana. Los síntomas predominantes fueron cefalea, fiebre y vómitos. La alteración del estado de conciencia se presentó en la mayoría de los casos como somnolencia. Las crisis convulsivas se registraron en 69% de los pacientes. En cuanto a la afección neurológica motora la más frecuente fue alteración de nervio craneal, encontrándose más afectado 6 nervio craneal. Los signos de irritación meníngea fueron documentados en 69% de los casos. El tiempo de evolución del cuadro clínico se reportó para la mayoría de los casos igual o mayor a 1 semana de sintomatología (67%). Comorbilidades descritas con mayor frecuencia fueron diabetes mellitus e infección por virus inmunodeficiencia humana. Otros factores de riesgo que se documentaron fueron etilismo crónico y uso drogas ilegales, en 35 pacientes no se identificó algún factor. En las pruebas de laboratorio empleadas el diagnóstico de los pacientes tratados por meningitis tuberculosa en líquido cefalorraquídeo, se identificó en el citoquímico con celularidad 193.23 leucocitos por mm3, linfocitos 77.17%, proteinorraquia 260.23 mg/dL y leucorraquia 58.21 mg/dL. El empleo del cultivo para tuberculosis fue solicitado en 42 casos, de estos únicamente 5 casos tuvieron cultivo positivo. Así mismo la determinación de ADA fue para 18 casos un valor ADA 11-20 UI/L, 11 casos con ADA 21-30 UI/L y 6 casos con valor superior a 31 UI/L. La baciloscopia fue negativa en 82% de los casos y la prueba GENE Xpert fue solicitada en 25 casos, de estos únicamente 4 tuvieron prueba positiva

Deformational brachycephaly in supine-sleeping infants.

OBJECTIVES: Medical dictionaries and anthropologic sources define brachycephaly as a cranial index (CI = width divided by length x 100%) greater than 81%. We examine the impact of supine sleeping on CI and compare orthotic treatment with repositioning. STUDY DESIGN: We compared the effect of repositioning versus helmet therapy on CI in 193 infants referred for abnormal head shape. RESULTS: Eighty percent of the infants had a pretreatment CI > 81%. Their initial mean CI at mean age 5.3 months was 89%, and after treatment, their mean CI was 87% (+/-2 SE = 0.9%) at mean age 9.0 months. For 92 infants with an initial CI at or above 90%, their initial mean CI of 96.1% was reduced to a mean of 91.9%. CONCLUSIONS: Post-treatment CI was 86% to 88%, CI in neonates delivered by cesarean section was 80%, and CI in supine-sleeping Asian children was 85% to 91%, versus 78% to 83% for prone-sleeping American children. Repositioning was less effective than cranial orthotic therapy in correcting severe brachycephaly. We recommend varying the head position when putting infants to sleep.

Determination and use of haplotypes: ethnic comparison and association of the lipoprotein lipase gene and coronary artery disease in Mexican-Americans.

PURPOSE: To illustrate an approach of deriving haplotypes for genetic association studies, using the lipoprotein lipase (LPL) gene and coronary artery disease. METHODS: Six polymorphisms sufficient to distinguish the most common haplotypes in the 3' end of LPL were identified by genotyping 10 polymorphisms in a small pilot population. These were used to haplotype LPL in large family samples of Mexican-Americans and non-Hispanic Caucasians. A case-control association study was performed comparing Mexican-Americans with and without coronary artery disease. RESULTS: The two ethnic groups exhibited significant genetic differences. Among Mexican-Americans, homozygosity for LPL haplotype 1 was protective against coronary artery disease (OR = 0.50, 95% CI 0.27-0.91). CONCLUSION: This study outlines the haplotype structure of the LPL gene, illustrates the utility of haplotype-based analysis in association studies, and demonstrates the importance of defining haplotype frequencies for different ethnic groups.

La ecocardiografía en la valoración y seguimiento pre y postoperatorio de la insuficiencia aórtica crónica / Echocardiography in the evaluation and pre and post-operative follow-up of chronic aortic insufficiency

En la insuficiencia aórtica crónica (IAoC) es difícil precisar el momento en que la sobrecarga volumétrica determina el deterioro miocárdico que desencadena los síntomas. A través de la comparación pre y postoperatoria se pretende conocer la utilidad de la ecocardiografía para definir el momento operatorio de la IAoC. Se estudian 13 pacientes con IAoC (con gradiente sistólico ventrículo - aorta menor de 20 mmHg), operados para substitución valvular aórtica y con seguimiento promedio de 13.7 meses. Dos pacientes fallecieron en el postoperatorio inmediato. Todos los restantes mostraron disminución de la cardiomegalia y pasaron a clase funcional I. El ecocardiograma mostró en el postoperatorio, reducción significativa (P<0,01) de los diámetros del ventrículo izquierdo y aumento de la fracción de expulsión (P<0.05). El acortamiento fraccional (AF) y la velocidad media de acortamiento circunferencial no mostraron cambios significativos. El índice diámetro sistólico final sobre velocidad normalizada de la pared posterior (DSF/VNPP) disminuyó significativamente y la velocidad media de relajación circunferencial (VMRC) aumentó (P<0.001) después del tratamiento quirúrgico. En el preoperatorio el DSF/VNPP y la VMRC tuvieron buena correlación con la presión diastólica final del ventrículo izquierdo (r=0.891 y -0.885 respectivamente). No se observó diferencia en la evolución de los pacientes con AF disminuído. Se concluye que el índice DSF/VNPP y la VMRC permiten tener una mejor valoración del volumen residual, de la ley de Frank-Starling y de la distensibilidad como expresiones de la función ventricular y ambos son útiles para precisar el momento en que es conveniente el cateterismo preoperatorio de los pacientes con IAoC

Informe técnico / Technical report

Tuvo como propósito la evaluación global de los avances alcanzados hasta ese momento en el Programa Nacional de Erradicación de los Desórdenes por Deficiencia de Yodo