Cut-off points of neck and waist circumference as predictors of obstructive sleep apnea in the Colombian population: a comparison with polysomnography

ABSTRACT BACKGROUND: Neck circumference (NC) is a useful anthropometric measure for predicting obstructive sleep apnea (OSA). Ethnicity and sex also influence obesity phenotypes. NC cut-offs for defining OSA have not been established for the Latin American population. OBJECTIVES: To evaluate NC, waist circumference (WC), and body mass index (BMI) as predictors of OSA in the Colombian population and to determine optimal cut-off points. DESIGN AND SETTING: Diagnostic tests were conducted at the Javeriana University, Bogota. METHODS: Adults from three cities in Colombia were included. NC, WC, and BMI were measured, and a polysomnogram provided the reference standard. The discrimination capacity and best cut-off points for diagnosing OSA were calculated. RESULTS: 964 patients were included (57.7% men; median age, 58 years) and 43.4% had OSA. The discrimination capacity of NC was similar for men and women (area under curve, AUC 0.63 versus 0.66, P = 0.39) but better for women under 60 years old (AUC 0.69 versus 0.57, P < 0.05). WC had better discrimination capacity for women (AUC 0.69 versus 0.57, P < 0.001). There were no significant differences in BMI. Optimal NC cut-off points were 36.5 cm for women (sensitivity [S]: 71.7%, specificity [E]: 55.3%) and 41 cm for men (S: 56%, E: 62%); and for WC, 97 cm for women (S: 65%, E: 69%) and 99 cm for men (S: 53%, E: 58%). CONCLUSIONS: NC and WC have moderate discrimination capacities for diagnosing OSA. The cut-off values suggest differences between Latin- and North American as well as Asian populations.

Esophagogastric Junction Contractile Integral (EGJ-CI) in Various Phenotypes of Gastroesophageal Reflux Disease (GERD)

Introduction: Two parameters of high-resolution esophageal manometry are used to observe the function of the esophagogastric junction (EGJ): the anatomical morphology of the EGJ and contractile vigor, which is evaluated with the esophagogastric junction contractile integral (EGJ-CI). To date, how these parameters behave in different gastroesophageal reflux disease (GERD) phenotypes has not been evaluated. Materials and methods: An analytical observational study evaluated patients with GERD confirmed by pH-impedance testing and endoscopy undergoing high-resolution esophageal manometry. The anatomical morphology of the EGJ and EGJ-CI was assessed and compared between reflux phenotypes: acid, non-acid, erosive, and non-erosive. Results: 72 patients were included (63% women, mean age: 54.9 years), 81.9% with acid reflux and 25% with erosive esophagitis. In the latter, a decrease in EGJ-CI (median: 15.1 vs. 23, p = 0.04) and a more significant proportion of patients with type IIIa and IIIb EGJ (83.3% vs 37.1%, p < 0.01) were found. No significant differences existed in the manometric parameters of patients with and without acid and non-acid reflux. Conclusion: In our population, EGJ-CI significantly decreased in patients with erosive GERD, suggesting that it could be used to predict this condition in patients with GERD. This finding is also related to a higher proportion of type III EGJ and lower pressure at end-inspiration of the lower esophageal sphincter in this reflux type.

Introducción: Para observar la función de la unión esofagogástrica (UEG) se utilizan dos parámetros de la manometría esofágica de alta resolución: la morfología anatómica de la UEG y el vigor contráctil, el cual se evalúa con la integral de contractilidad distal de la unión esofagogástrica (IC-UEG). Hasta el momento, no se ha evaluado cómo se comportan estos parámetros en los diferentes fenotipos de enfermedad por reflujo gastroesofágico (ERGE). Metodología: Estudio observacional analítico en el que se evaluaron pacientes con ERGE confirmado por pH-impedanciometría y endoscopia, llevados a manometría esofágica de alta resolución. Se evaluó la morfología anatómica de la UEG y la IC-UEG, y se comparó entre los diferentes fenotipos de reflujo: ácido, no ácido, erosivo y no erosivo. Resultados: Se incluyó a 72 pacientes (63% mujeres, edad media: 54,9 años), 81,9% con reflujo ácido y 25% con esofagitis erosiva. En este último grupo se encontró una disminución de la IC-UEG (mediana: 15,1 frente a 23, p = 0,04) y una mayor proporción de pacientes con UEG tipo IIIa y IIIb (83,3% frente a 37,1%, p < 0,01). No se encontraron diferencias significativas en los parámetros manométricos de los pacientes con y sin reflujo ácido y no ácido. Conclusión: En nuestra población, la IC-UEG estuvo significativamente disminuida en los pacientes con ERGE erosivo, lo que sugiere que podría ser utilizada como un predictor de esta condición en pacientes con ERGE. Este hallazgo también se relaciona con mayor proporción de UGE tipo III y menor presión al final de la inspiración del esfínter esofágico inferior en este tipo de reflujo.

Characterization of Achalasia Subtypes Based on High-Resolution Manometry in Patients at a Reference Hospital in Colombia

Introduction: Limited information is available regarding the clinical and manometric characteristics of different subtypes of achalasia. This study aims to describe these characteristics in patients treated at a prominent hospital in Colombia. Methods: This descriptive observational study included patients diagnosed with achalasia using high-resolution esophageal manometry at Hospital Universitario San Ignacio in Bogotá, Colombia, between 2016 and 2020. We documented the clinical manifestations, manometric findings, treatment approaches, and response to treatment based on the subtype of achalasia. Results: A total of 87 patients were enrolled, with a median age of 51 years, and 56.4% of them were female. The majority had type II achalasia (78.1%), followed by type I (16%) and type III (5.7%). All patients presented with dysphagia, 40.2% experienced chest pain, and 27.6% had gastroesophageal reflux. The clinical parameters, including integrated relaxation pressure value (IRP; median: 24 mmHg, interquartile range [IQR]: 19-33), upper esophageal sphincter pressure (UES; median: 63 mmHg, IQR: 46-98), and lower esophageal sphincter pressure (LES; median: 34 mm Hg, IQR: 26-45), were similar across the different subtypes. Esophageal clearance was incomplete in all patients. Among the 35 patients who received intervention, Heller's myotomy was the most commonly employed procedure (68.5%), followed by esophageal dilation (28.6%). All patients experienced symptomatic improvement, with a median pre-treatment Eckardt score of 5 (IQR: 5-6) and a post-treatment score of 1 (IQR: 1-2). Conclusions: Type II achalasia is the most prevalent subtype. The clinical and manometric findings, as well as treatment response, exhibit similarities among the different subtypes of achalasia. In Colombia, the outcomes of this condition align with those reported in other parts of the world.

Introducción: existe información limitada sobre las características clínicas y manométricas de los diferentes subtipos de acalasia. Este estudio describe dichas características en pacientes manejados en un hospital de referencia en Colombia. Método: estudio descriptivo observacional que incluye a pacientes con diagnóstico de acalasia por manometría esofágica de alta resolución manejados en el Hospital Universitario San Ignacio de Bogotá, Colombia, entre 2016 y 2020. Se describen las manifestaciones clínicas, hallazgos manométricos, tratamiento utilizado y respuesta al mismo según el subtipo de acalasia. Resultados: se incluyeron a 87 pacientes (mediana de edad: 51 años, 56,4% mujeres). La mayoría de tipo II (78,1%), seguido por tipo I (16%) y tipo III (5,7%). Todos presentaron disfagia, 40,2% dolor torácico y 27,6% reflujo gastroesofágico. La clínica y los valores del integral de presión de relajación (IRP; mediana: 24 mm Hg, rango intercuartílico [RIC]: 19-33), presión del esfínter esofágico superior (EES; mediana: 63 mm Hg, RIC: 46-98) y presión del esfínter esofágico inferior (EEI; mediana: 34 mm Hg, RIC: 26-45) fueron similares en los diferentes subtipos. El aclaramiento esofágico fue incompleto en todos los pacientes. Entre 35 pacientes que recibieron manejo intervencionista, la miotomía de Heller fue la intervención más utilizada (68,5%), seguido por la dilatación esofágica (28,6%). La totalidad de estos pacientes presentó una mejoría sintomática con la mediana de Eckardt pretratamiento de 5 (RIC: 5-6) y postratamiento de 1 (RIC: 1-2). Conclusiones: la acalasia tipo II es la más común. La clínica y los hallazgos manométricos y respuesta a tratamiento son similares entre los subtipos de acalasia. En Colombia, esta entidad se comporta de forma similar a lo reportado en otras partes del mundo.

Clinical characteristics, treatments, and outcomes of dificult biliary stones in a reference hospital in Colombia

The local experience and the success rate of different available treatments for dificult biliary stones in Colombia are poorly described. We made an observational study reporting patients treated for dificult biliary stones, at Hospital Universitario San Ignacio in Bogotá, Colombia between January 2015, and November 2021. Clinical characteristics, endoscopic retrograde cholangiopancreatography (ERCP) findings, and outcomes are presented. Additionally, the success rates of Endoscopic Sphincterotomy Plus Large Balloon Dilation (ESLBD), Mechanical Lithotripsy (ML), temporary stenting (TS), cholangioscopy-guided laser lithotripsy (CGLL), and surgery are described. A total of 146 patients were included (median age 69 years, IQR 58.5-78.5, 33.8% men). The median stone diameter was 15 mm (IQR 10 - 18 mm). One stone was presented in 39.9%, two stones in 18.2%, and ≥3 stones in the remaining stone. A 67.6% disproportion rate was observed between the stone and distal common bile duct. Successful stone extraction was achieved in 56.2% in the first procedure, 22.6% in the second, 17.1% in the third, 3.4% in the fourth, and 0.7% in the fifth procedures. The successful extraction rates were 56.8% for ESLBD, 75% for ML, 23.4% for TS, 57.7% for CGLL, and 100% for surgery. Endoscopic management of dificult stones is usually successful, although it usually requires 2 or more ERCPs procedures. The surgical requirements were low. ESLBD is an effective technique unlike TS. Few patients required advanced techniques such as ML or CGLL. Endoscopic procedures are associated with a low rate of complications.

La tasa de éxito de diferentes tratamientos de Cálculo Biliar Difícil (CBD) en Colombia no está descrita. Hemos realizado un estudio descriptivo observacional sobre el tratamiento de CBD en el Hospital Universitario San Ignacio en Bogotá, Colombia entre enero 2015 y noviembre 2021. Se presentan las características clínicas, hallazgos en la Colangiopancreatografía Retrógrada Endoscópica (CPRE) y desenlaces asociados. Adicionalmente, se describe la tasa de éxito de los pacientes tratados mediante esfinterotomía asociada a dilatación endoscópica con balón grande (EDEBG), litotripsia mecánica (LM), stent temporal (ST), litotripsia con láser guiada por colangioscopia (LLGC) y cirugía. 146 pacientes fueron incluidos (Mediana de edad 69 años, RIC 58,6-78,5). 33,8% eran hombres. La mediana del tamaño del CBD fue de 15 mm (RIC 10-18 mm). 39,9% tenían un solo cálculo, 18,2% tenían 2 y el resto ≥3 cálculos. 67,6% tenían desproporción entre el cálculo y el colédoco distal. La extracción exitosa se logró en 56,2% en el primer procedimiento, 22,6% en el segundo, 17,1% en el tercero, 3,4% en el cuarto y 0,7% en el quinto procedimiento. La tasa de extracción exitosa fue de 56,8% con EDEBG, 75% con LM, 23,4% con ST, 57,7% con LLGC y 100% con cirugía. El manejo endoscópico del CBD es usualmente exitoso. Sin embargo, requiere usualmente ≥2 CPRE. El tratamiento quirúrgico no es común. EDEBG es una técnica efectiva a diferencia del ST. Pocos pacientes requirieron técnicas avanzadas como LM o LLGC. Los métodos endoscópicos presentan una baja tasa de complicaciones.

Factors associated with a nonresponse to prone positioning in patients with severe acute respiratory distress syndrome due to SARS-CoV-2 / Fatores associados ao paciente com síndrome do desconforto respiratório agudo grave devido ao SARS-CoV-2 irresponsivo ao decúbito ventral

ABSTRACT Objective: To identify risk factors for nonresponse to prone positioning in mechanically ventilated patients with COVID-19-associated severe acute respiratory distress syndrome and refractory hypoxemia in a tertiary care hospital in Colombia. Methods: Observational study based on a retrospective cohort of mechanically ventilated patients with severe acute respiratory distress syndrome due to SARS-CoV-2 who underwent prone positioning due to refractory hypoxemia. The study considered an improvement ≥ 20% in the PaO2/FiO2 ratio after the first cycle of 16 hours in the prone position to be a 'response'. Nonresponding patients were considered cases, and responding patients were controls. We controlled for clinical, laboratory, and radiological variables. Results: A total of 724 patients were included (58.67 ± 12.37 years, 67.7% males). Of those, 21.9% were nonresponders. Mortality was 54.1% for nonresponders and 31.3% for responders (p < 0.001). Variables associated with nonresponse were time from the start of mechanical ventilation to pronation (OR 1.23; 95%CI 1.10 - 1.41); preintubation PaO2/FiO2 ratio (OR 0.62; 95%CI 0.40 - 0.96); preprone PaO2/FiO2 ratio (OR 1.88. 95%CI 1.22 - 2.94); and radiologic multilobe consolidation (OR 2.12; 95%CI 1.33 - 3.33) or mixed pattern (OR 1.72; 95%CI 1.07 - 2.85) compared with a ground-glass pattern. Conclusion: This study identified factors associated with nonresponse to prone positioning in patients with refractory hypoxemia and acute respiratory distress syndrome due to SARS-CoV-2 receiving mechanical ventilation. Recognizing such factors helps identify candidates for other rescue strategies, including more extensive prone positioning or extracorporeal membrane oxygenation. Further studies are needed to assess the consistency of these findings in populations with acute respiratory distress syndrome of other etiologies.

RESUMO Objetivo: Identificar fatores de risco em pacientes submetidos à ventilação mecânica devido à síndrome do desconforto respiratório agudo grave associada à COVID-19 e hipoxemia refratária irresponsivos ao decúbito ventral em um hospital terciário na Colômbia. Métodos: Estudo observacional baseado em coorte retrospectiva de pacientes submetidos à ventilação mecânica devido à síndrome do desconforto respiratório agudo grave associada ao SARS-CoV-2 em decúbito ventral devido à hipoxemia refratária. O estudo considerou resposta a melhora ≥ 20% na relação entre pressão parcial de oxigênio e fração inspirada de oxigênio após o primeiro ciclo de 16 horas em decúbito ventral. Os pacientes irresponsivos foram considerados casos, e os responsivos foram considerados controles. Controlamos as variáveis clínicas, laboratoriais e radiológicas. Resultados: Foram incluídos 724 pacientes (58,67 ± 12,37 anos, 67,7% do sexo masculino). Destes, 21,9% eram pacientes irresponsivos. A mortalidade foi de 54,1% nos irresponsivos e de 31,3% nos responsivos (p < 0,001). As variáveis associadas à ausência de resposta foram tempo do início da ventilação mecânica até o decúbito ventral (RC de 1,23; IC95% 1,10 - 1,41); relação entre pressão parcial de oxigênio e fração inspirada de oxigênio pré-intubação (RC de 0,62; IC95% 0,40 - 0,96); relação entre pressão parcial de oxigênio e fração inspirada de oxigênio anterior ao decúbito ventral (RC de 1,88; IC95% 1,22 - 2,94); e consolidação radiológica de múltiplos lobos (RC de 2,12; IC95% 1,33 - 3,33) ou padrão misto (RC de 1,72; IC95% 1,07 - 2,85) em comparação com um padrão em vidro fosco. Conclusão: Este estudo identificou fatores associados à ausência de resposta ao decúbito ventral em pacientes com hipoxemia refratária e síndrome do desconforto respiratório agudo devido ao SARS-CoV-2 em ventilação mecânica. O reconhecimento desses fatores ajuda a identificar os candidatos a outras estratégias de resgate, incluindo decúbito ventral mais prolongado ou oxigenação por membrana extracorpórea. São necessários novos estudos para avaliar a consistência desses achados em populações com síndrome do desconforto respiratório agudo por causa de outras etiologias.

Fatores associados à difícil canulação biliar em um centro de treinamento para intervenção endoscópica do trato biliar / Factors associated with difficult biliary cannulation in a training center for endoscopic intervention of the biliary tract

ABSTRACT Background This paper aims to determine factors associated with difficult biliary cannulation (DBC) that are identifiable before procedures. Methods This is a nested case-control study within a historical cohort in adult patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) from 2015-2019 in the Hospital Universitario San Ignacio, Colombia. This study assessed the associations among variables that could be identified before or at the beginning of procedures and the probability of DBC. These associations were evaluated through a bivariate and multivariate analysis. The study used criteria for DBC defined by the European Society of Gastrointestinal Endoscopy. Results A total of 498 ERCP performed in 376 patients were analyzed. Of all procedures, 144 (29%) fulfilled criteria for DBC. The multivariate analysis showed an association between DBC and the acute care hospital setting (OR:2.92; CI95% 1.70-5.01; P<0.001), redundant papilla (OR:7.26; CI95% 3.38-15.61; P<0.001), or peridiverticular papilla (OR:2.45; CI95% 1.38-4.36; P=0.002). No association was found between DBC and endoscopist's experience, bilirubin levels, or dilation of the biliary tract. Conclusion The DBC is a frequent event. Alterations in the papilla and ERCP performed in the acute care hospital setting are the principal factors associated with DBC. This information might be useful to predict DBC and establish healthcare and administrative strategies to reduce its implications.

RESUMO Contexto Este artigo tem como objetivo determinar fatores associados à dificuldade de canulação biliar que sejam identificáveis antes dos procedimentos. Métodos Trata-se de um estudo de caso-controle dentro de uma coorte histórica em pacientes adultos submetidos a colangiopancreatografia retrógrada endoscópica (CPRE) de 2015 a 2019 no Hospital Universitário San Ignacio, em Bogotá, Colômbia. Avaliou-se as associações entre variáveis que poderiam ser identificadas antes ou no início dos procedimentos e a probabilidade de difícil canulação biliar (DCB). Essas associações foram avaliadas por meio de análise bivariada e multivariada. O estudo utilizou critérios para DCB definidos pela Sociedade Europeia de Endoscopia Gastrointestinal. Resultados Foram analisados 498 CPRE em 376 pacientes. De todos os procedimentos, 144 (29%) preencheram critérios para DCB. A análise multivariada mostrou associação entre a DCB e o ambiente hospitalar de atenção aguda (OR:2,92; CI 95% 1,70-5,01; P<0,001), papila redundante (OR:7,26; CI95% 3,38-15,61; P<0,001), ou papila peridiverticular (OR:2,45; CI95% 1,38-4,36; P=0,002). Não foi encontrada associação entre a DCB e a experiência do endoscopista, dos níveis de bilirrubina ou da dilatação do trato biliar. Conclusão A DCB é um evento frequente. Alterações na papila e CPRE realizadas no ambiente hospitalar de cuidados agudos são os principais fatores associados a DCB. Essas informações podem ser úteis para prever a DCB e estabelecer estratégias de saúde e administrativas para reduzir suas implicações.

Pediatric Index of Mortality 2 e 3 são preditores de mortalidade iguais? Estudo de concordância com base em unidade de terapia intensiva / Are the Pediatric Index of Mortality 2 and 3 equal predictors of mortality? An intensive care unit-based concordance study

RESUMO Objetivo: Determinar a concordância da classificação do risco de mortalidade por meio do uso dos escores Pediatric Index of Mortality (PIM) 2 e 3. Métodos: Avaliação de uma coorte retrospectiva pela análise dos pacientes admitidos à unidade de terapia intensiva pediátrica entre abril de 2016 e dezembro de 2018. Calculamos o risco de mortalidade por meio do PIM 2 e do 3. Realizaram-se análises para determinar a concordância entre a classificação de risco obtida com ambas as escalas pela utilização do cálculo do Kappa não ponderado e linearmente ponderado. Resultados: Incluímos 722 pacientes, sendo que 66,6% destes tinham uma condição crônica. A mortalidade global foi de 3,7%. O coeficiente Kappa de concordância para classificação dos pacientes, segundo o risco com o PIM 2 e o 3, foi moderado: 0,48 (IC95% 0,43 - 0,53). Após ponderação linear, a concordância foi substancial: 0,64 (IC95% 0,59 - 0,69). Para pacientes de cirurgia cardíaca, a concordância para a classificação de risco foi regular: 0,30 (IC95% 0,21 - 0,39); após ponderação linear, a concordância foi apenas moderada: 0,49 (IC95% 0,39 - 0,59). O PIM 3 acusou um risco mais baixo do que o PIM 2 em 44,8% dos pacientes desse subgrupo. Conclusão: Nosso estudo comprova que o PIM 2 e o 3 não são clinicamente equivalentes e não devem ser usadas de forma intercambiável para avaliação da qualidade em diferentes unidades de terapia intensiva. Devem ser conduzidos estudos de validação antes que se utilizem os PIM 2 e 3 em situações específicas.

ABSTRACT Objective: To determine the concordance of mortality risk classification through the use of the Pediatric Index of Mortality (PIM) 2 and 3. Methods: Through a retrospective cohort, we evaluated patients admitted to the pediatric intensive care unit between April 2016 and December 2018. We calculated the mortality risk with the PIM 2 and 3. Analyses were carried out to determine the concordance between the risk classification obtained with both scales using unweighted and linearly weighted kappa. Results: A total of 722 subjects were included, and 66.6% had a chronic condition. The overall mortality was 3.7%. The global kappa concordance coefficient for classifying patients according to risk with the PIM 2 and 3 was moderate at 0.48 (95%CI 0.43 - 0.53). After linear weighting, concordance was substantial at 0.64 (95%CI 0.59 - 0.69). For cardiac surgery patients, concordance for risk classification was fair at 0.30 (95%CI 0.21 - 0.39), and after linear weighting, concordance was only moderate at 0.49 (95%CI 0.39 - 0.59). The PIM 3 assigned a lower risk than the PIM 2 in 44.8% of patients in this subgroup. Conclusion: Our study proves that the PIM 2 and 3 are not clinically equivalent and should not be used interchangeably for quality evaluation across pediatric intensive care units. Validation studies must be performed before using the PIM 2 or PIM 3 in specific settings.

Concordancia entre las escalas Marshall, Ranson y APACHE II como estimadoras de la morbimortalidad en pancreatitis aguda / Agreement between Marshall, Ranson and Apache II as estimators of morbidity and mortality in acute pancreatitis

Resumen Objetivo: actualmente, en Colombia están en uso diferentes escalas para estimar el riesgo de morbimortalidad en pacientes con pancreatitis, lo que genera incertidumbre a la hora de clasificar y manejar a estos pacientes. El objetivo de este estudio es analizar la concordancia entre las más usadas en una población atendida a 2670 metros sobre el nivel del mar (msnm). Materiales y métodos: se evaluaron 200 pacientes, entre 18 y 65 años, con diagnóstico de pancreatitis aguda y manejados en el Hospital Universitario San Ignacio de Bogotá (Colombia). Se estimaron tres escalas de riesgo y se clasificaron como pancreatitis con predicción de gravedad si los puntajes de APACHE II eran ≥8, Marshall modificada ≥2, o si tenían 3 o más criterios de Ranson positivos. Se determinó la concordancia entre los resultados usando el estadístico kappa. Resultados: según Marshall, el 45,5 % de los pacientes correspondieron a pancreatitis con predicción de gravedad, mientras que de acuerdo con APACHE II y Ranson se encontró este diagnóstico en un 39,5 % y un 38,5 %, respectivamente. El coeficiente kappa mostró una concordancia débil entre APACHE II y Ranson (kappa: 0,201; intervalo de confianza [IC], 95 %: 0,05-0,34), así como una concordancia pobre entre Ranson y Marshall (kappa: 0,18; IC, 95 %: 0,04-0,32). La concordancia entre APACHE y Marshall fue moderada (kappa: 0,42; IC, 95 %: 0,28-0,56). Conclusiones: existe un pobre acuerdo entre las diferentes escalas de clasificación de riesgo de pancreatitis usadas en Colombia, por lo que no pueden interpretarse como clínicamente equivalentes. Los datos de este estudio demuestran la necesidad de validar las distintas escalas en Colombia y en Latinoamérica. Además, sugieren que la escala de Marshall sobreestima el riesgo en ciudades por encima de los 2000 msnm.

Abstract Introduction: Different scales to estimate the risk of morbidity and mortality in patients with pancreatitis are currently in use in Colombia, which leads to uncertainty when classifying and treating these patients. Objective: This study seeks to analyze agreement between the most used scales to estimate the risk of patient morbidity and mortality in a population treated at 2,670 meters above sea level (m.a.s.l.). Materials and methods: Two hundred patients between 18 and 65 years old, diagnosed with acute pancreatitis, were evaluated and treated at the Hospital Universitario San Ignacio, Bogotá (Colombia). Three risk scales were used for the estimations. Scores ≥ 8 in the APACHE II system, ≥ 2 in the Modified Marshall Score, or 3 or more positive Ranson criteria were classified as pancreatitis with severity prognostic marker. Agreement between the results was determined using the Kappa coefficient. Results: According to the Marshall score, 45.5% of the cases were pancreatitis with predicted severity, while APACHE II and Ranson yielded scores of 39.5% and 38.5%, respectively. The Kappa coefficient showed weak agreement between APACHE II and Ranson (Kappa=0.201; 95%CI 0.05-0.34), poor agreement between Ranson and Marshall (Kappa=0.18; 95%CI 0.04-0.32), and moderate agreement between APACHE II and Marshall (Kappa=0.42; 95%CI 0.28-0.56). Conclusions: There is poor agreement between the pancreatitis severity scoring systems used in Colombia, so they cannot be interpreted as clinically equivalent. The data from this study demonstrate the need to validate the scales in Colombia and Latin America. They also suggest that the Marshall scale overestimates the risk in cities above 2,000 m.a.s.l.

Síndrome RS3PE (sinovitis simétrica seronegativa remitente con edema) como manifestación paraneoplásica de mesotelioma: reporte de un caso y revisión de la literatura / Remitting seronegative symmetrical synovitis with pitting oedema as a paraneoplastic manifestation of mesothelioma: A case report and review of the literature

RESUMEN El síndrome RS3PE (sinovitis simétrica seronegativa remitente con edema) fue descrito por McCarty (1985) como una forma benigna de artritis reumatoide de inicio en hombres mayores de 70 arios, con compromiso simétrico y asociada a edema de manos y pies. El enfoque de la poliartritis aguda en el adulto mayor debe incluir el síndrome RS3PE, en el que la pobre respuesta a esteroides y el compromiso multisistémico orientan hacia una naturaleza paraneoplásica, principalmente tumores sólidos (adenocarcinoma gástrico y pancreático), linfomas y leucemias. Se presenta el caso de un paciente con RS3PE como manifestación paraneoplásica de mesotelioma, una manifestación rara en este tipo de tumor.

A B S T R A C T Remitting seronegative symmetrical synovitis with pitting oedema (RS3PO) was described by McCarty (1985), as a benign form of rheumatoid arthritis that onset in men older than 70 years (80% of cases), with symmetrical and associated involvement of oedema of hands and feet. The approach of acute polyarthritis in the elderly should include the RS3PO syndrome, where poor steroid response and multisystem involvement oriented towards paraneoplastic nature, mainly with solid tumours (gastric and pancreatic adenocarcinoma), lymphomas and leukaemia. The case is presented of a patient with RS3PO as a paraneoplastic manifestation of mesothelioma, which is rare in this type of tumour.

Concordancia entre la tomografía axial computarizada de abdomen, la ultrasonografía endoscópica y la punción por aspiración con aguja fina en el diagnóstico de lesiones sólidas sugestivas de neoplasias malignas de páncreas / Diagnostic concordance of abdominal CT scans, Endoscopic Ultrasonography and Fine Needle Puncture Aspiration for solid pancreatic lesions suggestive of malignant neoplasms

Resumen Introducción y objetivo: la realización de pruebas para el diagnóstico de lesiones sólidas de páncreas conduce frecuentemente a resultados discordantes, lo que genera confusión y retraso en las decisiones terapéuticas. La concordancia entre los resultados de la tomografía axial computarizada de abdomen con contraste (TAC), la ultrasonografía endoscópica (USE) biliopancreática y la punción por aspiración con aguja fina guiada por ultrasonografía endoscópica (PAAF-USE) no ha sido evaluada en nuestro medio. Materiales y métodos: se evaluó una serie de pacientes adultos con masas sólidas del páncreas sospechosas de malignidad, atendidos en el Hospital Universitario San Ignacio (HUSI) de Bogotá (Colombia), en los cuales se realizaron, por lo menos, dos de las siguientes pruebas: TAC, USE o PAAF-USE. Se evaluó la concordancia de los resultados, definidos como compatibles con neoplasia, no compatibles con neoplasia o resultado no conclusivo. Resultados: se incluyeron 57 pacientes. Un alto porcentaje de estos, con USE compatible con neoplasia, tuvieron resultados discordantes con la TAC (33,3 %) y con la PAAF-USE (52,5 %). La concordancia entre imágenes y PAAF-USE fue mínima (kappa = 0,02; intervalo de confianza [IC] 95 %, 0,04-0,08). La probabilidad de detectar un compromiso vascular fue significativamente mayor en la USE (42,1 % frente a 23,8 %, p = 0,06) a diferencia del compromiso ganglionar, que fue detectado más frecuentemente por imágenes (TAC/resonancia magnética nuclear [RMN]) (23,8 % frente a 7,1 %, p = 0,01). Conclusiones: los resultados de este estudio sugieren un pobre acuerdo entre los diferentes métodos diagnósticos y advierten que es necesario implementar mejoras como la elastografía y medios de contraste, nuevas modalidades de aguja para la toma de muestras o la presencia de un citopatólogo in situ.

Abstract Introduction and objective: Diagnostic tests for solid pancreatic lesions frequently produce discordant results which lead to confusion and delays of therapeutic decisions. Concordance among abdominal computed tomography with contrast, endoscopic ultrasound (EUS) pancreatobiliary and EUS guided fine needle aspiration had not previously been evaluated in Colombia. Materials and methods: We evaluated a series of adult patients with solid pancreatic masses suspected of malignancy treated at the San Ignacio University Hospital in Bogotá, Colombia. At least two of the following tests were performed: CT scans, EUS, and EUS guided fine needle aspiration. Results were defined as compatible with neoplasia, not compatible with neoplasia or inconclusive. Concordance of results was then evaluated. Results: Fifty-seven patients were included. A high percentage EUS results compatible with neoplasia were discordant with CT scan results and with EUS guided fine needle aspiration results (33.3% and 52.5%, respectively). Agreement between imaging and EUS guided fine needle aspiration results was minimal (Kappa 0.02; 95% CI:-0.04 to 0.08). The probability of detecting vascular compromises was significantly higher for EUS (42.1% vs. 23.8%, p: 0.06), but lymph node compromises were detected more frequently by imaging (CT or MRI) (23.8% vs. 7.1%, p: 0.01). Conclusions: The results of this study suggest poor agreement between these diagnostic methods implying a need for improvements such as elastography and contrast media, new needle modalities for sampling, and/or the an on-site cytopathologist.

Total cholesterol in dyslipidemias. Is it a useful measure? / Colesterol total en dislipidemias. ¿Útil medirlo?

Abstract Introduction: the relationship between lipid fractions and cardiovascular risk is clear. However, the operational characteristics of total cholesterol (TC) for the diagnosis of dyslipidemias due to elevated LDL cholesterol (LDLC), hypertriglyceridemia and low HDL cholesterol (HDLC) are not clear. Objective: to establish the sensitivity (Sen) specificity (Spe) and predictive values (PPV and NPV) of TC (>200 mg/dL) for diagnosing various types of dyslipidemias. Materials and methods: a study of diagnostic tests using all the lipid profiles processed at the Hospital Universitario San Ignacio in Bogotá (Colombia) from January 2006 to January 2017. Sensitivity, Spe, PPV and NPV were calculated for each dyslipidemia and for each LDLC goal. Results: in 25,754 profiles, the average age was 53.6±18 years. The prevalence of elevated LDLC (based on the goals of 160, 130, 100, 70 or 55 mg/dL) was: 19.9%, 44.5%, 72.7%, 92.1% and 96.8%, respectively; for hypertriglyceridemia (>150 mg/dL) it was 44.7%, and for low HDLC (< 40 mg/dL) it was 33.9%. The sensitivity of TC (>200 mg/dL) for elevated LDLC according to the same goals was: 100%, 95%, 70%, 56% and 53%, with a specificity of: 59%, 81%, 94%, 95% and 92%; PPV=37%, 80%, 97%, 99% and 99%; and NPV=100%, 95%, 54%, 15% and 5.8%. For hypertrygliceridemia: Sen=61%, Spe=61%, PPV=55% and NPV=66%. For low HDLC: Sen=36%, Spe=42%, PPV=26% and NPV=54%. Conclusions: given the operational characteristics of TC>200 mg/dL, it should not be used as an isolated tool for diagnosing dyslipidemia due to LDLC, HDLC or hypertriglyceridemia. (Acta Med Colomb 2019; 44. DOI:https://doi.org/10.36104/amc.2019.1320).

Resumen Introducción: es clara la relation entre las fracciones lipídicas y riesgo cardiovascular, sin embargo, no son claras las características operativas del colesterol total (CT) para el diagnóstico de dislipidemias por colesterol LDL (C-LDL) elevado, hipertrigliceridemia y colesterol HDL (C-HDL) bajo. Objetivo: establecer sensibilidad (S), especificidad (E), y valores predictivos (VPP y VPN) del CT (>200 mg/dL) para diagnóstico de diferentes tipos de dislipidemias. Material y métodos: estudio de pruebas diagnosticas a partir de la totalidad de perfiles lipídicos procesados en el Hospital Universitario San Ignacio de Bogotá (Colombia), desde enero de 2006 hasta enero de 2017. Se calcularon S, E, VPP y VPN para cada dislipidemia y para cada meta de C-LDL. Resultados: en 25 754 perfiles, la edad promedio fue 53.6±18 años. Las prevalencias de C-LDL elevado (según metas de 160, 130, 100, 70 o 55 mg/dL) fueron: 19.9%, 44.5%, 72.7%, 92.1% y 96.8% respectivamente; hipertrigliceridemia (>150 mg/dL) 44.7% y C-HDL bajo (< 40 mg/dL) 33.9%. Las sensibilidades del CT (>200 mg/dL) para C-LDL elevado según las mismas metas fueron: 100%, 95%, 70%, 56% y 53% y especificidades: 59%, 81%, 94%, 95% y 92%. VPP=37%, 80%, 97%, 99% y 99%, y VPN=100%, 95%, 54%, 15% y 5.8%. Para hipertrigliceridemia: S=61%, E=61%, VPP=55% y VPN=66%. Para C-HDL bajo: S=36%, E=42%, VPP=26% y VPN=54%. Conclusiones: dadas las características operativas del CT>200 mg/dL, éste no debe ser utilizado como herramienta aislada para el diagnóstico de dislipidemia por C-LDL, por C-HDL, ni para hipertrigliceridemia. (Acta Med Colomb 2019; 44. DOI:https://doi.org/10.36104/amc.2019.1320).

Evaluación automática de la adherencia a las recomendaciones de manejo en falla cardiaca a partir de las historias clínicas electrónicas: herramienta EXEMED / Automatic evaluation of the adherence to recommendations for managing heart failure from the electronic health records: The EXEMED tool

Resumen Objetivo: La implementación de las guías de práctica clínica está limitada por la falta de herramientas que faciliten los procesos de auditoría y retroalimentación a los profesionales de salud. Este estudio evalúa la herramienta automatizada (EXEMED), diseñada para valorar la adherencia a las guías de práctica clínica a partir de la información consignada en las historias clínicas electrónicas. Métodos: En un grupo de 35 pacientes hospitalizados entre enero y marzo de 2016 se evaluó la adherencia a cinco recomendaciones contenidas en las guías de práctica clínica de falla cardiaca del Hospital Universitario San Ignacio. Se utilizó la herramienta automatizada EXEMED y se evaluó la validez de la misma comparando los resultados con la valoración realizada por una junta médica independiente. Se determinó concordancia entre los dos métodos usando el coeficiente kappa. Resultados: La adherencia a las diferentes recomendaciones osciló entre 0% para la determinación del perímetro abdominal al ingreso, hasta 97% para el uso de betabloqueadores al egreso. La proporción de acuerdo entre los dos métodos de evaluación estuvo por encima del 90% para todas las recomendaciones. El kappa para las diferentes recomendaciones fue de 0,78 (IC 95% 0,62-0,95) y 0,64 (0,48-0,80). El tiempo de evaluación se redujo de veinte a dos minutos por paciente con el uso de la herramienta EXEMED. Conclusiones: EXEMED es una herramienta válida y eficiente en la evaluación de la adherencia a las guías de práctica clínica. Se requieren nuevos estudios para evaluar el impacto de su uso asociado a retroalimentación a los clínicos, en la evolución a largo plazo de los pacientes con falla cardiaca.

Abstract Objective: The implementation of clinical practice guidelines is limited due to the lack of tools to carry out audits and provide feedback to the health professionals. In this study, an evaluation is performed using the automated (EXEMED) tool in order to assess the adherence to clinical practice guidelines from the information entered in the electronic health records. Methods: The adherence to 5 recommendations contained in the heart failure clinical practice guidelines was evaluated in a group of 35 patients admitted to the Hospital Universitario San Ignacio between January 2016 and March 2016. The automated EXEMED tool was used to assess this, by comparing the results obtained with the evaluation carried out by an independent medical committee. The kappa coefficient was used to determine the agreement between the two methods. Results: The adherence to the different recommendations varied between 0%, for the determination of the abdominal circumference, up to 97%, for the use of beta-blockers at discharge. Percentage agreement between the two evaluation methods was above 90% for all the recommendations. The kappa for the different recommendations was 0.78 (95% CI; 0.62-0.95) and 0.64 (0.48-0.80). The evaluation time was reduced from 20 minutes to 2 minutes with the use of the EXEMED tool. Conclusions: EXEMED is a valid and effective tool in the evaluation of adherence to clinical practice guidelines. Further studies are required to assess the impact of its used associated with feedback to the clinicians, in the long-term outcomes of patients with heart failure.

Investigación cualitativa reproducible: un camino que debemos empezar a recorrer / Qualitative reproducible research: A path we must begin to walk

El movimiento conocido como investigación reproducible (IR) ha venido ganando espacio dentro de la investigación cuantitativa como una forma de aumentar la confianza en sus resultados. El movimiento propone que los datos primarios y la codificación usada en el análisis de una investigación estén disponibles para que otros investigadores puedan verificar los resultados publicados y conducir análisis alternativos. Las ventajas asociadas a la IR aplican muy bien dentro del trabajo de los investigadores cualitativos, quienes no solo gozarían de mayor confianza y aceptación de los resultados de su investigación, sino que podrían beneficiarse al permitir que las personas interesadas entiendan sus hallazgos e, incluso, al favorecer la formación de redes de investigación y la construcción de conocimiento de forma colaborativa. Las limitaciones más grandes para que se pueda realizar investigación cualitativa (IC) reproducible están dadas por las restricciones éticas intrínsecas a hacer disponible de forma abierta los datos primarios y la codificación de los estudios. En el presente artículo se presentan algunas propuestas para superar estas dificultades, en lo referente al consentimiento informado y medidas para garantizar la confidencialidad de los datos, reconociendo que aún falta mucho camino superar estas dificultades. Así mismo, se presentan algunos pasos que ya se han avanzado para permitir que se desarrolle IC reproducible incluyendo el desarrollo de programas informáticos para el manejo de datos cualitativos, la disponibilidad de repositorios para hacer disponibles esos datos y los avances que se han desarrollado en la implementación de IR cuantitativa.

The movement known as reproducible research (RR) has won space in the quantitative research field as a way to increase the confidence in their results. The RR movement proposes that primary data and Computer codes used in the research must be publically available to let other researchers verify published results and to conduct alternative analysis. The advantages related to RR apply well to the qualitative researcher's work, and will increase the confidence and approval of their results, and additionally could provide advantages like the deeper understanding of their findings, the chance to create investigation networks and groups for collaborative knowledge building. The biggest limitations to produce qualitative reproducible research are ethical considerations associated with making sensitive information openlv available. The present article presents some proposals to overeóme these difficulcies associated with the process of obtaining informed consent and measures to guarantee the confidentiality of data, recognizing that there is much work to be done in this area. Additionally, some steps have been taken to facilitare reproducible qualitative research, including the development of software packages to manage qualitative data, the availability of repositories to make data available and advances developed in reproducible quantitative research implementation.

Guía colombiana de práctica clínica para el tratamiento de la diabetes mellitus tipo 2: falla al tratamiento inicial / Colombian Clinical Practice Guideline for Treatment of Type 2 Diabetes Mellitus: First Line Treatment Failure

Introducción: Existen diferentes opciones de manejo para pacientes con diabetes mellitus tipo 2 (DMT2) que ya iniciaron tratamiento farmacológico con metformina y no han alcanzado metas de control glucémico. Resulta prioritario definir pautas para escoger la mejor opción en estos pacientes, así como en aquellos que no han tenido un control óptimo con la combinación de dos medicamentos. Objetivo: Definir cuál es antidiabético de elección, entre sulfonilureas, tiazolidinedionas, inhibidores de DPP-4, agonista del receptor de GLP-1 o insulina basal, como segunda y tercera líneas de manejo en pacientes con DMT2. Métodos: Se elaboró la guía de práctica clínica, siguiendo los lineamientos de la guía metodológica del Ministerio de Salud y Protección Social colombiano. Se revisó la evidencia disponible de forma sistemática y se formularon las recomendaciones utilizando la metodología GRADE. Conclusiones: En pacientes con DMT2 y falla terapéutica al manejo con metformina como monoterapia (HbA1C > 7 %) se recomienda como primera opción adicionar un inhibidor DPP-4, como segunda opción adicionar inhibidor SGLT2 o sulfonilureas con bajo riesgo de hipoglucemia y como tercera opción agregar insulina basal a los pacientes que con la combinación de dos fármacos fallen en alcanzar su meta de HbA1C. Si la falla terapéutica se asocia con un IMC persistentemente ≥ 30, se sugiere la adición de un agonista de GLP-1 por el potencial beneficio sobre la reducción de peso.

Introduction: There are different options to treat type 2 diabetes (DMT2) patients who began treatment with metformin and have not reached therapeutic golds. It is imperative to define rules to choose the best option, in these patients, as in those who have not achieved an optimal control under combined therapy. Aim: To define the best option between sulfonylureas, thiazolidinediones, DPP4 inhibitors, GLP-1 agonist or basal insulin, as second or third line treatment, in patients with DMT2 who have not reached therapeutic golds with metformin or combined therapy. Methods: A clinical practice guide has been developed following the broad outline of the methodological guide from the Colombian Ministry of Health and Social Welfare, with the aim of systematically gathering scientific evidence and formulating recommendations using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. Conclusions: In patients with DMT2 who did not reach their therapeutic goal with metformin as a monotherapy (Hb1Ac <7%), addition of a second oral antidiabetic medication is recommended. it is recommended as a first step to add a DPP-4 inhibitor. It is suggested to add a SGLT2 inhibitor or a sulfonylurea having low risk of hypoglycemia as acceptable options. It is suggested to add basal insulin as a third antidiabetic medication if the combination of two pharmacological treatments does not enable the patient to reach and maintain the HbA1c goal. It is suggested to add a GLP-1 agonist if therapeutic failure appears in patients who remain obese (BMI ≥30 kg/m²), considering its potential to reduce weight.