Dental tooth decay profile in an institutionalized elder population of Northern Portugal / Perfil de cárie dentária numa população idosa institucionalizada do Norte de Portugal

Objectives: the purpose of this study was to assess the dental tooth decay profile of an elderly population from Northern Portugal. Material and Methods: this is a descriptive, cross-sectional study where a questionnaire, intended to assess the institutionalized elders oral health condition, was applied with the purpose of quantifying certain oral conditions. Tooth decay was assessed using the DMFT Index for the crown's tooth and the individual radicular caries index (RCIi) for the root's condition assessment. Univariate analysis and multivariable logistical regressions were performed (p < 0.05) using the IBM© SPSS© Statistics vs.19.0. Results: three hundred and seventy-two elderly participants were assessed with an average age of 78.8 years, of which 260 were women (69.9%). Of the sample 30.4% had no literacy and 18.3% were dependent on their daily oral hygiene care, 30.9% (95%CI:26.2%-35.6%) were edentulous and 84.9% (95%CI:81.3%-88.5%) had less than 20 teeth. The average number of teeth was 8.9 (± 8.7) and the DMFT was 25.6 (± 7.3). The RCIi for men was 44.3% (± 30.4%) and 39.4% (± 31.2%) for women. Using multivariate logistical regression model the outcome RCIi≥20% was shown to be significantly and positively associated with the use of removable partial dentures (metal partial dentures: OR = 5.348 (95% CI: 1.176-24,329; p = 0.030) as well as with daily tooth brushing (no toothbrushing: OR = 2.802 (95% CI: 1.445-5.433); p = 0.002). Conclusion: the prevalence of tooth decay in this elder institutionalized population of Northern Portugal is high, mostly due to bad oral hygiene habits associated to the use of metal removable partial dentures. Institutionalized elderly need protocols tailored to their oral health needs and integrated efforts in the institutions are needed to effectively answer the demands related to the elderly cognitive and motor skills (ageing deterioration) decline of physiological functions.(AU)

Objetivos: O objetivo deste estudo foi avaliar o perfil de cárie dentária numa população idosa do norte de Portugal. Material e Métodos: Trata-se de um estudo descritivo, transversal, onde foi aplicado um questionário destinado a avaliar a condição de saúde oral dos idosos institucionalizados, com o objetivo de quantificar determinadas condições orais. A cárie dentária foi avaliada usando o índice CPOD para a coroa do dente e o índice de cárie radicular individual (IRCi) para a avaliação da condição da raiz. Foi realizada análise univariada e regressão logística multivariável (p <0,05) usando o IBM© SPSS© Statistics vs.19.0. Resultados: avaliaram-se 372 idosos, com idade média de 78,8 anos, dos quais 260 eram mulheres (69,9%). Da amostra, 30,4% não tinham escolaridade e 18,3% dependiam de outros para realizar os seus cuidados diários de higiene oral; 30,9% (IC95%: 26,2%-35,6%) eram desdentados e 84,9% (IC95%: 81,3%-88,5%) tinham menos de 20 dentes. O número médio de dentes foi de 8,9 (± 8,7) e o CPOD foi de 25,6 (± 7,3). O ICRi para o género masculino foi de 44,3% (± 30,4%) e de 39,4% (± 31,2%) para o feminino. Usando o modelo de regressão logística multivariada, o resultado ICRi≥20% mostrou-se significativa e positivamente associado ao uso de próteses parciais removíveis (próteses parciais esqueléticas: OR= 5,348 (IC95%: 1,176-24,329; p = 0,030), bem como com escovagem diária (sem escovagem: OR= 2,802 (IC95%: 1,445-5,433); p = 0,002). Conclusão: a prevalência de cárie dentária nesta população idosa institucionalizada do Norte de Portugal é alta, principalmente devido à má higiene oral e hábitos associados ao uso de próteses parciais removíveis esqueléticas. Idosos institucionalizados precisam de protocolos adaptados às suas necessidades de saúde oral e esforços integrados nas instituições para atender efetivamente às necessidades relacionadas com o declínio das funções fisiológicas do idoso, cognitivas e motoras (deterioração do envelhecimento). (AU)

CR-POSSUM and Surgical Apgar Score as predictive factors for patients' allocation after colorectal surgery / Escore CR-POSSUM e Índice de Apgar Cirúrgico como fatores preditivos para a alocação de pacientes após cirurgia colorretal

Abstract Background and objectives Surgical patients frequently require admission in high-dependency units or intensive care units. Resources are scarce and there are no universally accepted admission criteria, so patients' allocation must be optimized. The purpose of this study was to investigate the relationship between postoperative destination of patients submitted to colorectal surgery and the scores ColoRectal Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (CR-POSSUM) and Surgical Apgar Score (SAS) and, secondarily find cut-offs to aid this allocation. Methods A cross-sectional prospective observational study, including all adult patients undergoing colorectal surgery during a 2 years period. Data collected from the electronic clinical process and anesthesia records. Results A total of 358 patients were included. Median score for SAS was 8 and CR-POSSUM had a median mortality probability of 4.5%. Immediate admission on high-dependency units/intensive care units occurred in 51 patients and late admission in 18. Scores from ward and high-dependency units/intensive care units patients were statistically different (SAS: 8 vs. 7, p < 0.001; CR-POSSUM: 4.4% vs. 15.9%, p < 0.001). Both scores were found to be predictors of immediate postoperative destination (p < 0.001). Concerning immediate high-dependency units/intensive care units admission, CR-POSSUM showed a strong association (AUC 0.78, p = 0.034) with a ≥9.16 cut-off point (sensitivity: 62.5%; specificity: 75.2%), outperforming SAS (AUC 0.67, p = 0.048), with a ≤7 cut-off point (sensitivity: 67.3%; specificity: 56.1%). Conclusions Both CR-POSSUM and SAS were associated with the clinical decision to admit a patient to the high-dependency units/intensive care units immediately after surgery. CR-POSSUM alone showed a better discriminative capacity.

Resumo Justificativa e objetivos Os pacientes cirúrgicos com frequência precisam de internação em unidade de alta dependência ou unidade de terapia intensiva. Os recursos são escassos e não há critérios de admissão universalmente aceitos; portanto, a alocação dos pacientes precisa ser aprimorada. O objetivo primário deste estudo foi investigar a relação entre o destino dos pacientes após cirurgia colorretal e o Índice de Apgar Cirúrgico (IAC) e o escore CR-POSSUM - do inglês ColoRectal Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity - e, secundariamente, descobrir pontos de corte para auxiliar essa alocação. Métodos Estudo prospectivo de observação transversal, incluiu todos os pacientes adultos submetidos à cirurgia colorretal durante um período de dois anos. Os dados foram coletados do prontuário clínico eletrônico e dos registros de anestesia. Resultados Foram incluídos 358 pacientes. A mediana para o IAC foi 8 e para a probabilidade de mortalidade no CR-POSSUM, 4,5%. A admissão imediata em unidade de alta dependência/unidade de terapia intensiva ocorreu em 51 pacientes e a admissão tardia em 18. Os escores dos pacientes na enfermaria e na unidade de alta dependência/unidade de terapia intensiva foram estatisticamente diferentes (tempo de internação: 8 vs. 7, p < 0,001; CR-POSSUM: 4,4% vs. 15,9%, p < 0,001). Os dois escores foram preditivos do destino imediato pós-cirurgia (p < 0,001). Em relação à admissão imediata em UAD/UTI, CR-POSSUM mostrou uma forte associação (ASC 0,78; p = 0,034) com um ponto de corte ≥ 9,16 (sensibilidade: 62,5%; especificidade: 75,2%), superou o IAC (ASC 0,67, p = 0,048), com ponto de corte ≤ 7 (sensibilidade: 67,3%; especificidade: 56,1%). Conclusões Tanto o CR-POSSUM quanto o IAC foram associados à decisão clínica de admitir um paciente em unidade de alta dependência/unidade de terapia intensiva imediatamente após a cirurgia. CR-POSSUM isolado mostrou uma capacidade discriminativa melhor.

Urgent tracheostomy: four-year experience in a tertiary hospital / 世界急诊医学杂志（英文）

@#BACKGROUND: Urgent airway management is one of the most important responsibilities of otolaryngologists, often requiring a multidisciplinary approach. Urgent surgical airway intervention is indicated when an acute airway obstruction occurs or there are intubation difficulties. In these situations, surgical tracheostomy becomes extremely important.METHODS: We retrospectively studied the patients who underwent surgical tracheostomy from 2011 to 2014 by an otolaryngologist team at the operating theater of the emergency department of a tertiary hospital. Indications, complications and clinical evolution of the patients were reviewed.RESULTS: The study included 56 patients (44 men and 12 women) with a median age of 55 years. The procedure was performed under local anesthesia in 21.4％ of the patients. Two (3.6％) patients were subjected to conversion from cricothyrostomy to tracheostomy. Head and neck neoplasm was indicated in 44.6％ of the patients, deep neck infection in 19.6％, and bilateral vocal fold paralysis in 10.7％. Stridor was the most frequent signal (51.8％). Of the 56 patients, 15 were transferred to another hospital. Among the other 41 patients, 21 were decannulated (average time: 4 months), and none of them were cancer patients. Complications occurred in 5 (12.2％) patients: hemorrhage in 3, surgical wound infection in 1, and cervico-thoracic subcutaneous emphysema in 1. No death was related to the procedure.CONCLUSION: Urgent tracheostomy is a life-saving procedure for patients with acute airway obstruction or with diffi cult intubation. It is a safe and effective procedure, with a low complication rate, and should be performed before the patient''s clinical status turns into a surgical emergency situation.

Screening for primary aldosteronism in an argentinian population: a multicenter prospective study

Objectives Primary aldosteronism (PA) is characterized by the autonomous overproduction of aldosterone. Its prevalence has increased since the use of the aldosterone (ALD)/plasma renin activity (PRA) ratio (ARR). The objective of this study is to determine ARR and ARC (ALD/plasma renin concentration ratio) cut-off values (COV) and their diagnostic concordance (DC%) in the screening for PA in an Argentinian population.Design multicenter prospective study.Subjects and methods We studied 353 subjects (104 controls and 249 hypertensive patients). Serum aldosterone, PRA and ARR were determined. In 220 randomly selected subjects, 160 hypertensive patients and 60 controls, plasma renin concentration (PRC) was simultaneously measured and ARC was determined.Results According to the 95th percentile of controls, we determined a COV of 36 for ARR and 2.39 for ARC, with ALD ≥ 15 ng/dL. In 31/249 hypertensive patients, ARR was ≥ 36. PA diagnosis was established in 8/31 patients (23/31 patients did not complete confirmatory tests). DC% between ARR and ARC was calculated. A significant correlation between ARR and ARC (r = 0.742; p < 0.0001) was found only with PRA > 0.3 ng/mL/h and PRC > 5 pg/mL. DC% for ARR and ARC above or below 36 and 2.39 was 79.1%, respectively.Conclusion This first Argentinian multicenter study determined a COV of 36 for ARR and 2.39 for ARC. Applying an ARR ≥ 36 in the hypertensive group, we confirmed PA in a higher percentage of patients than the previously reported one in our population. As for ARC, further studies are needed for its clinical application, since DC% is acceptable only for medium range renin values.

Prueba de supresión con Dexametasona 1mg en una población de individuos con normopeso, sobrepeso y obesidad: Estudio multicéntrico / The Overnight 1mg Dexamethasone Test in Healthy Subjects with Normal Weight, Overweight and Obesity: a Multicentric Study

La prueba de supresión con dexametasona-1mg oral nocturna evalúa la conservación del mecanismo de retroalimentación negativa normal ejercido por los glucocorticoides sobre el eje hipotálamo-hipófiso-adrenal (HH-A), siendo ampliamente utilizada en el algoritmo diagnóstico de sospecha de síndrome de Cushing (SC). Pero la concentración de cortisol sérico matinal postinhibición que define la supresiblidad normal ha sido motivo de controversia, con valores variables desde el original =5 ug/dl (=138 nmol/L) hasta una cifra =1,8 ug/dl (=50 nmol/L) últimamente. Asimismo, es controvertida la respuesta en la obesidad, donde está descripta una alteración del eje H-H-A. Por lo tanto, el Departamento de Suprarrenal de SAEM llevó a cabo este estudio multicéntrico con el objetivo de definir la concentración de cortisol sérico obtenida luego de la administración de dexametasona 1mg nocturna, en una población de sujetos sanos de nuestro país con peso normal; concomitantemente, se evaluaron individuos con sobrepeso y con obesidad simple para comparar su respuesta respecto de los sujetos normopeso. Se estudiaron 80 individuos sanos, 60 mujeres y 20 hombres, de 15 a 66 años de edad, que fueron divididos en tres grupos según el índice de masa corporal (IMC): Normopeso, IMC=19-24,9 kg/m2, n=39; Sobrepeso, IMC=25-29,9 Kg/m2, n=21; y Obesos, IMC = 30 kg/m2, n=20. Se administró dexametasona 1 mg vía oral a las 23 hs. y se determinó la cortisolemia a las 8hs. de la mañana siguiente. Las determinaciones se centralizaron en un solo laboratorio y fueron realizadas por el equipo de radioinmunoensayo (RIA) de DSL, sensiblidad analítica de 0,5 ug/dl. Paralelamente en 10 sujetos, se determinó la cortisolemia postinhibición en las mismas muestras con otro equipo analítico, RIA-DPC. Resultados: Los resultados de la cortisolemia postsupresión en los tres grupos estudiados se expresan como X± DS (rango): en el grupo normopeso fue de 2,10± 0,77 ug/dl (0,78-3,40); en el sobrepeso, 1,94± 0,66 ug/dl (0,962,90); y en los obesos, 1,86 ± 0,63 ug/dl (0,85-3,30), no observándose diferencias significativas entre los tres grupos estudiados (test de Kruskall Wallis Dunn, p=0,319). En los 10 sujetos cuyas muestras fueron simultáneamente analizadas por RIA-DSL y por RIA-DPC, se observaron marcadas diferencias en 8/10, siendo la mediana de cortisol sérico obtenida por RIA-DPC de 0,5µg/dl, significativamente menor a la obtenida por RIA-DSL, de 2,2 µg/dl (test de Wilcoxon, p=0,002). Conclusiones: Debemos destacar que este es el primer estudio multicéntrico que evalúa la respuesta a la inhbibición con dexametasona 1 mg en nuestro medio. En esta primera etapa, demostramos que una concentración de cortisol sérico post 1 mg de dexametasona oral nocturna = 3,4 µg/dl (= 93,8nmol/l), determinada por RIA-DSL, caracteriza la respuesta normal de nuestra población de sujetos sanos. Ello es independiente del peso corporal, ya que los sujetos con normopeso, sobrepeso y obesidad suprimieron a valores similares. No se observó falta de supresión en ningún caso estudiado. Por otra parte, dadas las marcadas diferencias de valores halladas en las mismas muestras cuando son analizadas por equipos diferentes de RIA, es fundamental referir los resultados al método y equipo utilizados y estandarizar las pruebas clínicas con la metodología específica empleada en cada laboratorio.

The overnight oral dexamethasone test assesses the normal negative feedback of cortisol on the hypothalamic-pituitary-adrenal axis (H-P-A) 1. It is widely used in the screening of Cushing’s Syndrome (CS) 3,4,5. But the cut-off values for the normal response remains controversial: originally it was considered as 5 ug/dl and in the last years it was reported as 1.8 ug/dl 4. Likewise, there is no agreement about the suppression values in obesity, where a hyperactivity of the H-P-A axis has been reported. Therefore, the Adrenal Department of the Argentine Society of Endocrinology and Metabolism (SAEM) studied 80 healthy subjects recruited from ten hospitals of Buenos Aires in order to assess the normal response in our population. Sixteen women and twenty men, aged 15-66 years old (X = 39.2ys), were classified into three groups, according to their body mass index (BMI): normal weight, BMI- 19-24.9 kg/m2 (n= 39); overweight, BMI- 25-29.9 kg/m2 (n=21) and obese subjects, BMI> 30 kg/m2 (n=20). They had to be euthyroid and free of corticosteroid treatment, contraceptive pills, hormone replacement therapy, rifampicin and psychotropic drugs at the time of the study. Subjects referring drug abuse, alcoholism, depression, cardiovascular, and renal disorders and,obviously, adrenal diseases were excluded from the study. Dexamethasone 1mg per os was administered at 11p.m. and blood was withdrawn at 8 a.m. on the next morning to determine plasma cortisol concentration. Determinations were centralized in one laboratory and the RIA-DSL (Diagnostic System Laboratories-radioimmunoassay) was used. Additionally, in ten subjects plasma cortisol was also determined in the same blood samples by another radioimmunoassay kit, RIA-DPC (Diagnostic Products Corporation). The Kruskall-Dunn test was used to compare the plasma cortisol levels post-1mg dexamethasone among the three groups studied. In the 10 patients whose determinations were made in the same blood samples by two different RIA-kits (DSL and DPC),the Wilcoxon test was used to compare the results of plasma cortisol between RIA-DSL and RIA-DPC. Results: The results are expressed as X ± SD ug/dl (range). Plasma cortisol levels after 1mg-dexamethasone were: 2.10 ± 0.77 ug/dl ( 0.78- 3.40 ug/dl) in the normal weight goup; 1.94 ± 0.66 ug/dl (0.96-2.90) in the overweight group and 1.86 ± 0.63 ug/dl (0.85-3.30) in the obese subjects (Table I); no significant differences were observed among the three groups (p=0.319). According to these results, the cut-off value for plasma cortisol post-dexamethasone in the normal weight subjects was considered as = 3.4 ug/dl (93.8 nmol/L) using RIA-DSL. Similar suppression values were obtained in the overweight and obese subjects - 2.9 and 3.3 ug/dl, respectively. No false positive results were observed, either individually or in each group (Fig 1). In the 10 subjects whose blood cortisol was simultaneously determined in the same samples by RIA-DSL and RIA-DPC, the median for plasma cortisol was 2.2 ug/dl for the first and 0.5 ug/dl for the latter, respectively, with a significant difference between both RIA kits (p=0.002). (Table II). Conclusions: In this first stage, the present multicentric study shows that a plasma cortisol level post - 1mg dexamethasone suppression of = 3.4 ug/dl ( 93.8 nmol/L) defines our normal population response, with no significant differences among normal weight,overweight and obese subjects. Furthermore, we wish to point out that the cortisol values must be referred to the method and commercial kits used in each laboratory, since significant differences can be observed in the same blood samples when different kits are used, such as we and other authors have observed. We wish to remark the importance of our study, which is the first in its characteristics in Argentina. Furthermore, in a second stage, we plan to enlarge the sample number and to determine blood cortisol in the same samples by using different methods, in order to obtain a standardized cortisol suppression level. We also plan to study patients with confirmed CS and pseudocushing states in order to assess the sensitivity and specificity of the 1mg-dexamethasone suppression test in our population.

Diagnostico molecular de neoplasia endocrina multiple tipo 1 (MEN-1) en una familia argentina afectada / Molecular diagnosis in an Argentine family with multiple endocrine neoplasia type-1 (MEN-1)

La Neoplasia Endocrina Múltiple tipo 1 (MEN-1) es una enfermedad genética autosómica dominante caracterizada por la presencia de neoplasias de paratiroides, páncreas endocrino e hipófisis anterior. El locus del MEN-1 se localizó en el cromosoma 11 banda q13. El análisis de ligamiento por restricción (A.L.) y las determinaciones hormonales permiten el diagnóstico precoz de los individuos afectados. Se estudió en su lugar de residencia a los veinte integrantes vivos de la primera, segunda y tercera generación de una familia con MEN-1, para determinar la presencia de marcadores genéticos moleculares en el locus del gen MEN-1 11q13, por A.L. y detectar en la tercera generación portadores presintomáticos por A.L. y enfermos por determinaciones hormonales y evaluación clínica. Se hallaron dos marcadores polimórficos a ambos lados de locus del MEN-1: PYGM y D11S987, haplotipos segregados por los dos integrantes enfermos de la segunda generación, heredados del padre, en un enfermo y un portador presintomático de la tercera generación. El resto de los integrantes no heredó el alelo ligado al MEN-1 con una confiabilidad del 99 per ciento. Con respecto a los hallazgos clínicos y de laboratorio encontramos en la tercera generación dos portadores de los marcadores moleculares del MEN-1, uno con litiasis renal, parathormona (PTH), prolactina (PRL) y glucagon elevados y otro con PTH elevada asintomático. Entre los que heredaron el alelo normal, prolactina (PRL) y glucagon elevados y otro con PTH elevada asintomático. Entre los que heredaron el alelo normal, uno presentó glucagon elevado, otro gastrina elevada y otro PTH elevada, todos asintomáticos. Establecimos el diagnóstico molecular de la familia estudiada y se detectó un portador presintomático. De acuerdo a la literatura y nuestros hallazgos, la precisión del diagnóstico molecular nos permitiría excluir del seguimiento a los portadores del alelo normal.