Effects of prevention programmes on injury risk in military personnel: a systematic review with meta-analysis.

INTRODUCTION: Exercise programmes have been used to prevent injuries in military personnel, as they can reduce modifiable risk factors for injuries. Our aim was to review the literature to evaluate the effects of different exercise protocols on the prevention of injuries in military personnel. METHODS: A systematic literature review examined the effects of different exercise protocols on the prevention of musculoskeletal injuries in the military. Several databases were explored to find experimental studies that investigated the effects of prevention programmes on the risk of injury. We have extracted from the studies: profile of participants, sample size, study design and characteristics of the control group (CG), the type of intervention and the relative risk (RR) in the experimental group and CG, with their significance levels. For data analysis, we used the RevMan V.5.3 software. The measure of RR was investigated. The risk of publication bias was analysed with Begg's test. RESULTS: A total of 13 694 titles and studies were recovered from the databases and by manual search. After the removal of duplicate titles and studies that did not meet the eligibility criteria, 17 studies were selected. The protocols were composed of neuromuscular training, stretching, agility training or combined exercises. The meta-analysis showed that injury prevention exercise programmes reduced the risk of musculoskeletal injuries in military personnel by 14% (RR=0.86; 95% CI=0.76 to 0.98). CONCLUSION: Injury prevention exercise programmes promoted a slight reduction in the risk of musculoskeletal injuries in military personnel. LEVEL OF EVIDENCE: Very low. TRIAL REGISTRATION NUMBER: CRD 42017077946.

Dual shape recovery of red blood cells flowing out of a microfluidic constriction.

Micropipette aspiration, optical tweezers, rheometry, or ecktacytometry have been used to study the shape recovery of healthy human Red Blood Cells (RBCs) and measure associated relaxation times of the order of 100-300 ms. These measurements are in good agreement with the Kelvin-Voigt model, which describes the cell as a visco-elastic material, predicting that its relaxation time only depends on cell intrinsic properties. However, such mechanical solicitation techniques are far from being relevant regarding RBC solicitation in vivo. In this paper, we report for the first time the existence of two different behaviors of the RBC shape recovery while flowing out of a microfluidic constricted channel. The calculation of the viscous stress corresponding to the frontier between the two recovery modes confirms that the RBC resistance to shear µ is the elastic property dominating the transition between the two recovery behaviors. We also quantified associated recovery times τ r and report values as low as 4 ms-which is almost two decades smaller than the typical RBC relaxation time-at high viscosity and flow velocity of the carrier fluid. Although we cannot talk about relaxation time because the cell is never at rest, we believe that the measured shape recovery time arises from the coupling of the cell intrinsic deformability and the hydrodynamic stress. Depending on the flow conditions, the cell mechanics becomes dominant and drives the shape recovery process, allowing the measurement of recovery times of the same order of magnitude than relaxation times previously published. Finally, we demonstrated that the measurement of the shape recovery time can be used to distinguish Plasmodium falciparum (causing malaria) infected RBCs from healthy RBCs.

SciFi detector and associated method for real-time determination of profile and output factor for small fields in stereotactic radiotherapy.

PURPOSE: For determining small-field profile and output factor during stereotactic radiotherapy quality assurance (QA) procedures, we propose a novel system based on the scintillating fiber (SciFi) detector with output image acquisition and processing to allow real-time monitoring of profile and output factor. MATERIALS AND METHODS: The employed detector is a SciFi detector made of tissue-equivalent scintillating plastic fibers arranged in 6-layer fiber ribbons with a fiber pitch of 275 µm in each layer. The scintillating signal at the detector output is acquired by a sCMOS (scientific complementary metal-oxide-semiconductor) camera and represents the projected field profile along the fibers axis. An iterative reconstruction method of the field from its projected profile based on a priori knowledge of some features of the radiation field defined by the stereotactic cones is suggested. The detector with implemented data processing has been tested in clinical conditions, for determining beam profiles and output factors, using cone collimators of different sizes from 4 to 15 mm diameter. The detector under test was placed at 1.4 cm depth and 98.6 cm source to surface distance (SSD) in a water-equivalent phantom and irradiated by a 6 MV photon beam. RESULTS: The reconstructed field profiles obtained from the detector are coherent with data from EBT3 radiochromic films, with differences within ±0.32 mm for both the FWHM and the penumbra region. For real-time determination of the field output factor, the measured data are also in good agreement with data independently determined by the French Institute for Radiological Protection and Nuclear Safety (IRSN) based on radiochromic films and thermoluminescent 1 × 1 mm2 micro-cubes dosimeters (TLD). The differences are within ±1.6% for all the tested cone sizes. CONCLUSIONS: We propose and have tested a SciFi plastic scintillating detector with an optimized signal processing method to characterize small fields defined by cone collimators. It allows the determination of key field parameters such as full width at half maximum (FWHM) and field output factors. The results are consistent with those independently measured using TLD and radiochromic films. As the SciFi detector does not require a correction factor, it is in line with the International Atomic Energy Agency (IAEA) and the American Association of Physicists in Medicine (AAPM) TRS-483 recommendations, and can be suitable for online QA of small radiation fields used in photon beam radiotherapy, and is compatible with MRI-LINAC.

The influence of high-intensity interval training on anthropometric variables of adults with overweight or obesity: a systematic review and network meta-analysis.

OBJECTIVE: The goal of this study was to evaluate the influence of high-intensity interval training (HIIT) on anthropometric variables in adults afflicted with overweight or obesity and to compare the effects with those of moderate-intensity continuous training. METHODS: A computer literature search was performed for HIIT intervention studies that evaluated anthropometric variables in adults afflicted with overweight or obesity. RESULTS: Of the 857 articles retrieved in the electronic search, 48 met the inclusion criteria. The analyses demonstrated that HIIT was effective in decreasing body mass (-1.45 kg [95% CI: -1.85 to -1.05 kg]), body mass index (-0.44 kg m-2 [95% CI: -0.59 to -0.30 kg m-2 ]), waist circumference (-2.3 cm [95% CI: -3.1 to -1.4 cm]), waist/hip ratio (-0.01 [95% CI: -0.02 to -0.00]), body fat percentage (-1.29% [95% CI: -1.70% to -0.87%]) and abdominal visceral fat area (-6.83 cm2 [95% CI: -11.95 to -1.71 cm2 ]). When considering equalization between the two methods (energy expenditure or workload matched), no differences were found in any measure except body mass (for which HIIT was superior). CONCLUSIONS: High-intensity interval training and moderate-intensity continuous training results were similar, particularly when equalization between the two methods was considered. Thus, HIIT can be used as a secondary method for the treatment of obesity in adults.

An overview of osteopathy graduates' perceived preparedness at transition from educational environment to clinic environment one year after graduation: a cross sectional study.

BACKGROUND: This study investigated perceived preparedness to practice, one year after graduation across osteopathic education institutions (OEIs) and explored possible differences between countries where osteopathy is regulated (Reg) and countries where it is not (Unreg). METHODS: Two hundred forty-five graduates from 7 OEIs in 4 European countries, already assessed in a previous study, were contacted one year after their graduation to complete the survey. Survey tools included a questionnaire to assess perceived preparedness to practice: Association of American Medical Colleges (AAMC) questionnaire, and a questionnaire to collect socio-demographic information and practice characteristics. RESULTS: One hundred sixty-eight graduates (68.6%) completed the survey. The AAMC mean score one year after the graduation (23.19; confidence interval 22.81-23.58) was significantly higher than in the previous study (17.58; 16.90-18.26) (p < 0.001). A difference was also found between Reg (23.49; 23.03-23.95) and Unreg (22.34; 21.74-22.94) (p = 0.004). Osteopaths with a previous healthcare degree scored significantly higher on AAMC score (25.53; 24.88-26.19) than osteopaths without a previous healthcare degree (22.33; 21.97-22.69) (p < 0.001). Regulation and a previous degree were the only significant independent variables in the most predictive multivariate linear model. The model had an r2 = 0.33. CONCLUSIONS: Graduates from OEIs where osteopathy is regulated felt significantly better prepared to practice than Unreg. Systematic information searches about graduates' perception of preparedness to practice, may enable OEIs to strengthen their existing curricula to ensure their graduates are effectively prepared to practice.

Fate of petroleum hydrocarbons in bioturbated pristine sediments from Caleta Valdés (Patagonia Argentina): An ex situ bioassay.

Petroleum can pollute pristine shorelines as a consequence of accidental spills or chronic leaks. In this study, the fate of petroleum hydrocarbons in soft pristine sediment of Caleta Valdés (Argentina) subject to ex situ simulated oil pollution was assessed. Sedimentary columns were exposed to medium and high concentrations of Escalante Crude Oil (ECO) and incubated in the laboratory during 30 days. Levels of aliphatic hydrocarbons at different depths of the sedimentary column were determined by gas chromatography. Oil penetration was limited to the first three centimetres in both treatments, and under this depth, hydrocarbons were clearly biogenic (terrestrial plants) as in the whole sedimentary column of the control assay. Bioturbation by macrobenthic infauna was strongly impacted by oil pollution which resulted in reduced sediment oxygenation and low burial of petroleum hydrocarbons. This may partly explain the limited hydrocarbon biodegradation observed, as indicated by the relatively high values of the ratios nC17/pristane, nC18/phytane, and total resolved aliphatic hydrocarbons/unresolved complex mixture. Correspondingly, at the end of the experiment the most probable number of hydrocarbon-degrading bacteria reached ~ 103 MPN g-1 dry weight. These values were lower than those found in chronically polluted coastal sediments, reflecting a low activity level of the oil-degrading community. The results highlight the low attenuation capacities of Caleta Valdés pristine sediments to recover its original characteristics in a short time period if an oil spill occurs. In this work, we present a novel and integrative tool to evaluate the fate of petroleum hydrocarbons and their potential damage on pristine sediments.

Osteocalcin improves insulin resistance and inflammation in obese mice: Participation of white adipose tissue and bone.

AIMS/HYPOTHESIS: The discovery of osteocalcin, a protein synthetized by osteoblasts, as a hormone that has positive effects on insulin resistance, contributed to support the concept of bone as an endocrine organ. However, very little is known about the molecular pathways involved in osteocalcin improved-insulin resistance. The present study aimed to investigate the mechanisms of action of osteocalcin on insulin resistance and inflammation in obese mice and 3T3-L1 adipocytes. METHODS AND RESULTS: Lean control, saline-treated obese and uncarboxylated osteocalcin (uOC)-treated obese mice were subjected to insulin tolerance test in vivo. Blood was collect for biochemical/metabolic profile analysis; and, skeletal muscle, white adipose tissue (WAT) and bone were collected for protein (Western blotting) and mRNA (RT-qPCR) analysis. uOC effects on insulin resistance and inflammation were also investigated in 3T3-L1 adipocytes challenged with tumor necrosis factor. Osteocalcin treatment improved in vivo insulin resistance in obese mice. In WAT, osteocalcin had positive effects such as (1) WAT weight reduction; (2) upregulation of glucose transporter (GLUT) 4 protein and its mRNA (Slc2a4); (3) improved insulin-induced AKT phosphorylation; (4) downregulation of several genes involved in inflammation and inflammassome transcriptional machinery, and (5) reduction of the density of macrophage in crown-like structures (histomorphometrical analysis). Notably, in 3T3-L1 adipocytes, osteocalcin restored Slc2a4/GLUT4 content and reduced the expression of inflammatory genes after TNF-a challenge; moreover, osteocalcin treatment increased AKT phosphorylation induced by insulin. Finally, it was observed that in bone, osteocalcin improves insulin resistance by increasing insulin-induced AKT phosphorylation and reducing the expression of genes involved in bone insulin resistance, resulting in increased secretion of uncarboxylated osteocalcin in circulation. CONCLUSION: We provided some mechanisms of action for osteocalcin in the amelioration of insulin resistance in obesity: in WAT, osteocalcin improves insulin resistance by decreasing inflammation, and increasing insulin signaling and the expression of Slc2a4/GLUT4; and, in bone, osteocalcin increases the secretion of uncarboxylated osteocalcin by improving insulin resistance.

Hazardous metal pollution in a protected coastal area from Northern Patagonia (Argentina).

The San Antonio Bay is a protected natural coastal area of Argentina that has been exposed to mining wastes over the last three decades. Iron and trace metals of potential concern to biota and human health (Cd, Pb, Cu, and Zn) were investigated in the sediments from the bay and in the soils of the Pile (mining wastes). Concentrations of Cd (45 mg kg-1), Pb (42,853 mg kg-1), Cu (24,505 mg kg-1), and Zn (28,686 mg kg-1) in the soils Pile exceeded guidelines for agricultural, residential, and industrial land uses. Risk assessment due to exposure to contaminated soils (Pile) was performed. Hazard quotients were superior to non-risk (HQ >1) for all trace metals, while accumulative hazard quotient index indicated a high risk for children (HI = 93) and moderate for adults (HI = 9). In the bay, sediments closest to the Pile (mudflat and salt marsh) exceeded sediment quality guidelines for protection of biota. Results of different acid extraction methods suggest that most of the pseudototal content was potentially mobile. Principal component analysis indicated that the sites near the Pile (Encerrado channel) were more polluted than the distal ones. Tissues of Spartina spp. located within Encerrado channel showed the highest metal levels among all studied sites. These results show that the problem still persists and the mining wastes are the sources of the pollution. Furthermore, the Encerrado channel is a highly impacted area, as it is shown by their metal enriched sediments.

Effects of doxorubicin administration on bone strength and quality in sedentary and physically active Wistar rats.

Doxorubicin (DOX) is used in pediatric cancer treatment. This study assessed the effects of 7 weeks of DOX and 10-week recovery on bone quality and biomechanical properties in sedentary and exercised Wistar rats. DOX decreases femur diaphysis radial growth and biomechanical properties. Some of these DOX effects were aggravated by exercise. INTRODUCTION: Bone growth in pre-pubertal years critically influences adult fracture risk. DOX is widely used in the treatment of pediatric cancers, but there is limited evidence on its potential negative effects on bone growth. Exercise improves bone growth in children, but there is no evidence if it protects against DOX-induced bone toxicity. This study investigates the early and intermediate effects of a 7-week course of DOX on bone histomorphometry and strength in sedentary and exercised growing animal models. METHODS: Sixty-eight male Wistar rats (8 weeks) were treated with DOX (2 mg kg-1) or vehicle for 7 weeks and afterward housed in standard cages or in cages with a running wheel and killed 2 or 10 weeks after last DOX administration. Femurs and blood were collected for assaying geometry, trabecular microarchitecture (histology), biomechanical properties (three-point bending and shearing of the femoral neck), bone calcium content and density (atomic absorption spectroscopy), and bone turnover markers (ELISA). RESULTS: DOX treatment reduced the femur diaphysis radial growth, with DOX-treated animals having a lower tissue area, cortical area, cortical thickness, and moment of inertia. DOX also decreased distal femur trabecular bone volume and trabecular number and increased trabecular separation. Femur diaphysis stiffness and maximum load were also reduced in past DOX-treated animals. Exercise was shown to worsen the effects of past DOX treatment on the femur diaphysis mechanical properties. CONCLUSION: DOX negatively affects bone geometry, trabecular microarchitecture, and femur mechanical properties in growing Wistar rats. Exercise further aggravates the detrimental effects of past DOX treatment on bone mechanical properties.

Tratamiento temprano de la mordida en tijera unilateral / Early treatment of unilateral scissors bite

La mordida en tijera unilateral es una maloclusión poco frecuente en la dentición primaria. El objetivo de este reporte es describir el caso de un paciente de 4 arios 7 meses de edad que presentaba esta alteración en el sector posterior izquierdo. Esta alteración fue tratada con el uso un arco transpalatino y elásticos cruzados intermaxilares. El tratamiento implico un tiempo de 6 meses y 3 meses adicionales como periodo de contención. Como resultado se logró establecer una adecuada relación intermaxilar...

The unilateral scissors bite is a rare malocclusion in the primary dentition. The purpose of this report is to describe the case of a patient 4 years 7 months old, who presented this alteration in the left posterior sector. This alteration was treated with a transpalatal arch and cross elastics. The treatment involved a period of 6 months and 3 additional months as a retention period. As a result it was possible to establish an adequate intermaxillary relationship...

Caracterização da condição física e fatores de risco cardiovascular de policiais militares rodoviários / Caracterización de la condición física y factores del riesgo cardiovascular de la policía de carreteras / Characterization of the physical condition and cardiovascular risk of highway police officers

Objetivo: O objetivo do presente estudo foi verificar os níveis de condição, composição corporal e pressão arterial de policiais rodoviários do estado do Paraná - Brasil. Método: Fizeram parte da amostra 52 oficiais do sexo masculino (idade: 38,3 ± 6,3 anos, massa corporal: 89,6 ± 18,4 kg) de diferentes patentes. Foram realizadas diversas mensurações para obtenção do índice de massa corporal (IMC), circunferência de cintura (CC), relação cintura/quadril (RCQ), composição corporal por meio da espessura de dobras cutâneas, potência aeróbia estimada indiretamente em teste de esforço ergométrico, resistência muscular localizada (RML) de membros superiores e abdominal e os níveis pressóricos foram aferidos por método auscultatório. Resultados: Considerando as variáveis analisadas, os policiais rodoviários apresentaram IMC de 28,6 ± 4,8 kg/m2, risco cardiovascular elevado (95,4 ± 10,8 cm) para CC e alto (0,92 ± 0,05) para RCQ. O percentual de gordura corporal apresentou-se acima dos valores recomendáveis (23,6 ± 4,3 %) para saúde, a potência aeróbia estimada foi considerada boa (34,8 ± 1,1 ml/kg/min), a RML de membros superiores (21 ± 8 repetições) e foi obtida por realização dos testes de abdominal e flexão de braço, respectivamente (28 ± 8 repetições) foram classificadas como média e uma parcela importante dos oficiais (23 %) mostraram-se com níveis pressóricos elevados. Conclusão: Os policiais militares rodoviários mostraram-se com níveis inadequados de condição física, apresentando excesso de peso e adiposidade corporais, e, uma parcela importante, exibiu níveis pressóricos elevados, sugerindo elevado risco cardiovascular

Objetivo. Evaluar los niveles de aptitud, composición corporal y de la presión arterial de la policía de carreteras en el estado de Paraná, Brasil. Método. Se analizó a 52 oficiales del sexo masculino (38,3 ± 6,3 años, y 89,6 ± 18,4 kg). Fueron realizadas diferentes mediciones para la obtención del índice de masa corporal (IMC); la circunferencia de cintura (CC); el índice cintura/cadera (ICC). La composición corporal se midió por medio del espesor del pliegue cutáneo; la potencia aeróbica se estimó indirectamente mediante una prueba de esfuerzo en una cinta ergométrica; la fuerza muscular de los miembros superiores se midió mediante el número de flexiones y la del abdomen por el número de abdominales y la presión arterial fue medida por auscultación. Resultados. Los policías presentaban un IMC clasificado como obesidad leve (28,6 ± 4,8 kg/m2); la CC de alto riesgo (95,4 ± 10,8 cm); el ICC alto (0,92 ± 0,05); el porcentaje de grasa corporal por encima de los valores recomendados (23,6 ± 4,3 %); la potencia aeróbica buena (34,8 ± 1,1 ml/kg/min); la RM de los miembros superiores (21 ± 8 repeticiones) y del abdomen (28 ± 8 repeticiones) medias, y una proporción significativa (23 %) de los policías presentaron niveles de presión arterial alterada. Conclusión. En base a estos resultados, fue posible verificar que aunque la policía ha mantenido buenos niveles de potencia aeróbica y fuerza muscular, presentaron exceso de peso e índices que indican alto riesgo cardiovascular (AU)

Objective. The aim of this study was to assess the physical fitness, body composition and blood pressure of highway police officers in the state of Paraná, Brazil. Method. The sample consisted of 52 male (38.3 ± 6.3 years old, 89.6 ± 18.4 kg) where the following determinations were performed: body mass index (BMI); waist circumference (WC); waist/hip ratio (WHR); body composition (skinfold thickness); aerobic power (indirectly estimated in a treadmill test); muscle strength of the upper limbs was measured by the number of push-ups and abdominal strength by the number of crunches (ES) and blood pressure (measured by auscultatory method). Results. The highway police officers had a BMI classified as mild obesity (28.6 ± 4.8 kg/m2), and a higher cardiovascular risk as determined by WC (95.4 ± 10.8 cm) and WHR (0.92 ± 0.05). The percentage of body fat was above the recommended values (23.6 ± 4.3 %) but the aerobic power was considered good (34.8 ± 1.1 ml/kg/min). Mean ES upper body (21 ± 8 repetitions) and abdomen (28 ± 8 repetitions) were qualified as fair but mean blood pressure was considered high in 23 % of the police officers. Conclusion. Based on our results it was possible to conclude that although the police officers presented good levels of aerobic power and muscle strength, they are overweight and showed a higher cardiovascular risk (AU)

[Cognitive remediation therapy for children and adolescents with anorexia nervosa in France: an exploratory study]. / Évaluation d'un programme de remédiation cognitive au sein d'un groupe d'enfants et d'adolescents anorexiques français: étude exploratoire.

OBJECTIVE: Cognitive remediation therapy (CRT) seems to be increasingly interesting in the treatment of anorexia nervosa for adult patients. We attempted to apply this support to a group of young inpatients, initially to assess its feasibility and acceptability, and then to improve its content for therapeutic application and future research. METHODS: Ten 12- to 17-year-old inpatients with primary DSM-IV diagnosis of anorexia nervosa participated in a 10-week intervention program with a one-hour group session of CRT per week. All 10 patients were assessed before the intervention and those who completed the 10 sessions were assessed after. Assessment included a clinical examination by a psychiatrist, a battery of clinical inventories, and set-shifting tests. Moreover, each patient wrote a letter providing feedback on the intervention for subsequent analysis. RESULTS: Only two patients completed all 10 sessions, the other eight who were discharged from the hospital in the meantime could not attend the sessions for practical reasons. After the 10 sessions, an improvement in BMI and in measured levels of some psychopathological symptoms was observed in our two patients. Most neuropsychological task performances were improved after cognitive remediation. Feedback from the 10 patients was generally positive. CONCLUSION AND IMPLICATIONS FOR PRACTICE: This preliminary investigation suggests that cognitive remediation therapy is acceptable and feasible in this population. Replication of these findings requires a larger sample, improvement of the trial design, more sensitive measures, and another training format to avoid loss of so many participants.

Benthic nutrient fluxes and sediment oxygen consumption in a full-scale facultative pond in Patagonia, Argentina.

The study of benthic metabolism is an interesting tool to understand the process that occurs in bottom water at wastewater stabilization ponds. Here, rates of benthic oxygen consumption and nutrient exchange across the water-sludge interface were measured in situ using a benthic chamber. The research was carried out during autumn, winter, and summer at a municipal facultative stabilization pond working in a temperate region (Puerto Madryn city, Argentina). Both a site near the raw wastewater inlet (Inlet station) and a site near the outlet (Outlet station) were sampled. Important seasonal and spatial patterns were identified as being related to benthic fluxes. Ammonium release ranged from undetectable (autumn/summer - Inlet station) to +30.7 kg-NH4(+) ha(-1) d(-1) (autumn - Outlet station), denitrification ranged from undetectable (winter - in both sites) to -4.0 kg-NO3(-) ha(-1) d(-1) (autumn - Outlet station), and oxygen consumption ranged from 0.07 kg-O2ha(-1) d(-1) (autumn/summer - Outlet station) to 0.84 kg-O2ha(-1) d(-1) (autumn - Inlet station). During the warmer months, the mineralization of organic matter from the bottom pond acts as a source of nutrients, which seem to support the important development of phytoplankton and nitrification activity recorded in the surface water. Bottom processes could be related to the advanced degree and efficiency of the treatment, the temperature, and probably the strong and frequent wind present in the region.

Obstructive sleep apnea affects hospital outcomes of patients with non-ST-elevation acute coronary syndromes.

STUDY OBJECTIVE: We aimed to test the hypothesis that clinically suspected obstructive sleep apnea (OSA) independently predicts worse in-hospital outcome in patients with non-ST elevation acute coronary syndromes. DESIGN: At admission, individuals were evaluated for clinical probability of OSA by the Berlin Questionnaire. Primary cardiovascular endpoint was defined as the composite of death, nonfatal myocardial infarction, or refractory angina during hospitalization. SETTING: Coronary care unit. PATIENTS: There were 168 consecutive patients admitted with unstable angina or non-ST elevation acute myocardial infarction. MEASUREMENTS AND RESULTS: During a median hospitalization of 8 days, the incidence of cardiovascular events was 13% (12 deaths, 4 nonfatal myocardial infarctions, and 6 refractory anginas.) Incidence of the primary endpoint was 18% in individuals with high probability of OSA, compared with no events in individuals with low probability (P = 0.002). After logistic regression adjustment for the Global Registry of Acute Coronary Events (GRACE) risk score, anatomic severity of coronary disease, and hospital treatment, probability of OSA remained an independent predictor of events (odds ratio [OR] = 3.4; 95% confidence interval [CI] = 1.3 - 9.0; P = 0.015). Prognostic discrimination of the GRACE score, measured by a C-statistic of 0.72 (95% CI = 0.59-0.85), was significantly improved to 0.82 (95% CI = 0.73-0.92) after inclusion of OSA probability in the predictive model (P = 0.03). CONCLUSION: Considering the independent prognostic and incremental value of suspected OSA, this condition may represent an aggravating factor for patients with non-ST elevation acute coronary syndrome.

Accuracy of the GRACE and TIMI scores in predicting the angiographic severity of acute coronary syndrome.

BACKGROUND: The accuracy of the GRACE and TIMI scores in predicting coronary disease extension in patients with non-ST-elevation acute coronary syndromes (ACS) has not been established. OBJECTIVE: To assess the hypothesis that the GRACE and TIMI risk scores satisfactorily predict coronary disease extension in patients withnon-ST-elevation ACS undergoing coronary angiography. METHODS: Individuals meeting the objective criteria for ACS and undergoing coronary angiography during hospitalization were consecutively assessed. Angiographic coronary disease was described as follows: quantification of coronary disease extension by using Gensini score; presence of any coronary artery obstruction (> 70% or > 50% when affecting left main coronary artery); and presence of severe disease (three-vessel disease or affecting the left main coronary artery). RESULTS: Of 112 patients assessed, a positive correlation of the Gensini score was observed with the GRACE (p = 0.017) and TIMI (p = 0.02) scores, but that association was weak (r = 0.23 and r = 0.27; respectively). The GRACE score could predict neither obstructive coronary disease (area under the ROC curve = 0.57; 95% CI = 0.46 - 0.69), nor severe coronary disease (ROC = 0.59; 95% CI = 0.48 - 0.70). The TIMI score proved to be a modest predictor of coronary disease (ROC = 0.65; 95% CI = 0.55 - 0.76) and of severe coronary disease (ROC = 0.66; 95% CI = 0.56 - 0.76). CONCLUSION: (1) There is a positive association between the values of the TIMI or GRACE scores and the extension of coronary artery disease in patients with ACS; (2) however, the degree of that association is not sufficient to make those scores accurate predictors of coronary angiography results.

Acurácia dos escores GRACE e TIMI na predição da gravidade angiográfica da síndrome coronariana aguda / Accuracy of the GRACE and TIMI scores in predicting the angiographic severity of acute coronary syndrome

FUNDAMENTO: A acurácia dos escores GRACE e TIMI em predizer a extensão da doença coronariana em pacientes com síndromes coronarianas agudas sem supradesnivelamento do segmento ST (SCA) não está estabelecida. OBJETIVO: Testar a hipótese de que os escores de risco GRACE e TIMI predizem satisfatoriamente a extensão da doença coronariana, em pacientes com SCA submetidos a coronariografia. MÉTODOS: Indivíduos admitidos com critérios objetivos de SCA e que realizaram coronariografia durante o internamento foram consecutivamente analisados. A doença coronariana angiográfica foi descrita de três formas: quantificação da extensão da doença coronariana pelo escore de Gensini; presença de qualquer obstrução coronariana (> 70% ou > 50% quando tronco de coronária esquerda); presença de doença severa (triarterial ou tronco de coronária esquerda). RESULTADOS: Em 112 pacientes avaliados, observou-se correlação positiva do escore de Gensini com os escores GRACE (p = 0,017) e TIMI (p = 0,02), porém essa associação foi de fraca magnitude (r = 0,23 e r = 0,27; respectivamente). O escore GRACE não foi capaz de predizer doença coronariana obstrutiva (área abaixo da curva ROC = 0,57; 95%IC = 0,46 - 0,69), nem doença coronariana severa (ROC = 0,59; 95%IC = 0,48 -0,70). O Escore TIMI se mostrou modesto preditor em relação à presença de doença coronariana (ROC = 0,65; 95%IC = 0,55 - 0,76) e presença de doença severa (ROC = 0,66; 95%IC = 0,56 - 0,76). CONCLUSÃO: (1) Existe associação positiva entre o valor dos escores TIMI ou GRACE e a extensão da doença coronária em pacientes com SCA; (2) No entanto, o grau dessa associação não é suficiente para que esses escores sejam preditores acurados dos resultados da coronariografia.

BACKGROUND: The accuracy of the GRACE and TIMI scores in predicting coronary disease extension in patients with non-ST-elevation acute coronary syndromes (ACS) has not been established. OBJECTIVE: To assess the hypothesis that the GRACE and TIMI risk scores satisfactorily predict coronary disease extension in patients withnon-ST-elevation ACS undergoing coronary angiography. METHODS: Individuals meeting the objective criteria for ACS and undergoing coronary angiography during hospitalization were consecutively assessed. Angiographic coronary disease was described as follows: quantification of coronary disease extension by using Gensini score; presence of any coronary artery obstruction (> 70% or > 50% when affecting left main coronary artery); and presence of severe disease (three-vessel disease or affecting the left main coronary artery). RESULTS: Of 112 patients assessed, a positive correlation of the Gensini score was observed with the GRACE (p = 0.017) and TIMI (p = 0.02) scores, but that association was weak (r = 0.23 and r = 0.27; respectively). The GRACE score could predict neither obstructive coronary disease (area under the ROC curve = 0.57; 95% CI = 0.46 - 0.69), nor severe coronary disease (ROC = 0.59; 95% CI = 0.48 - 0.70). The TIMI score proved to be a modest predictor of coronary disease (ROC = 0.65; 95% CI = 0.55 - 0.76) and of severe coronary disease (ROC = 0.66; 95% CI = 0.56 - 0.76). CONCLUSION: (1) There is a positive association between the values of the TIMI or GRACE scores and the extension of coronary artery disease in patients with ACS; (2) however, the degree of that association is not sufficient to make those scores accurate predictors of coronary angiography results.

Análise de causalidade da relação entre sangramento e letalidade de Síndromes Coronarianas Agudas / Causality analysis of the relationship between bleeding and lethality in Acute Coronary Syndromes

FUNDAMENTO: Eventos hemorrágicos em Síndromes Coronarianas Agudas (SCA) apresentam associação independente com óbito em registros multicêntricos internacionais. No entanto, essa associação não foi testada em nosso meio e a verdadeira relação causal entre sangramento e óbito não está plenamente demonstrada. OBJETIVO: Testar as hipóteses de que: (1) sangramento maior é preditor independente de óbito hospitalar em SCA; (2) a relação entre esses dois desfechos é causal. MÉTODOS: Incluídos pacientes com critérios pré-definidos de angina instável, infarto sem supradesnivelamento do ST ou infarto com supradesnivelamento do ST. Sangramento maior durante o internamento foi definido de acordo com os tipos 3 ou 5 da Classificação Universal de Sangramento. Regressão logística e análise da sequência de eventos foram utilizadas para avaliar a associação entre sangramento e óbito. RESULTADOS: Dentre 455 pacientes estudados, 29 desenvolveram sangramento maior (6,4%; 95%IC = 4,3-9,0%). Esses indivíduos apresentaram mortalidade hospitalar de 21%, comparados a 5,6% nos pacientes sem sangramento (RR = 4,0; 95%IC = 1,8-9,1; P = 0,001). Após ajuste para escore de propensão, sangramento maior permaneceu preditor de óbito hospitalar (OR = 3,34; 95%IC = 1,2-9,5; P = 0,02). Houve 6 óbitos dentre 29 pacientes que sangraram. No entanto, análise detalhada da sequência de eventos demonstrou relação causal em apenas um caso. CONCLUSÃO: (1) Sangramento maior é preditor independente de óbito hospitalar em SCA; (2) O papel do sangramento como marcador de risco predomina sobre seu papel de fator de risco para óbito. Essa conclusão deve ser vista como geradora de hipótese a ser confirmada por estudos de maior tamanho amostral. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0).

BACKGROUND: Hemorrhagic events in Acute Coronary Syndromes (ACS) have been independently associated with death in international multicenter registries. However, that association has not been tested in Brazil and the true causal relationship between bleeding and death has not been completely shown. OBJECTIVE: To test the following hypotheses: (1) major bleeding is an independent predictor of in-hospital death in ACS; (2) the relationship between those two endpoints is causal. METHODS: This study included patients meeting predefined criteria of unstable angina, non-ST-segment elevation myocardial infarction or ST-segment elevation myocardial infarction. Major bleeding during hospitalization was defined according to the Bleeding Academic Research Consortium (types 3 or 5). Logistic regression and analysis of the sequence of events were used to assess the association between bleeding and death. RESULTS: Of the 455 patients studied, 29 experienced major bleeding (6.4%; 95% CI = 4.3-9.0%). They had in-hospital mortality of 21%, as compared with 5.6% of those not experiencing bleeding (RR = 4.0; 95% CI = 1.8-9.1; P = 0.001). After adjusting for the propensity score, major bleeding remained as a predictor of in-hospital death (OR = 3.34; 95% CI = 1.2-9.5; P = 0.02). Of the 29 patients who experienced bleeding, six died. However, the detailed analysis of the sequence of events showed causal relationship only in one case. CONCLUSION: (1) Major bleeding is an independent predictor of in-hospital death in ACS; (2) the role of bleeding as a risk marker overcomes that as a risk factor for death. This conclusion should be seen as a hypothesis generator to be confirmed by larger-sample studies. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0).

Causality analysis of the relationship between bleeding and lethality in Acute Coronary Syndromes.

BACKGROUND: Hemorrhagic events in Acute Coronary Syndromes (ACS) have been independently associated with death in international multicenter registries. However, that association has not been tested in Brazil and the true causal relationship between bleeding and death has not been completely shown. OBJECTIVE: To test the following hypotheses: (1) major bleeding is an independent predictor of in-hospital death in ACS; (2) the relationship between those two endpoints is causal. METHODS: This study included patients meeting predefined criteria of unstable angina, non-ST-segment elevation myocardial infarction or ST-segment elevation myocardial infarction. Major bleeding during hospitalization was defined according to the Bleeding Academic Research Consortium (types 3 or 5). Logistic regression and analysis of the sequence of events were used to assess the association between bleeding and death. RESULTS: Of the 455 patients studied, 29 experienced major bleeding (6.4%; 95% CI = 4.3-9.0%). They had in-hospital mortality of 21%, as compared with 5.6% of those not experiencing bleeding (RR = 4.0; 95% CI = 1.8-9.1; P = 0.001). After adjusting for the propensity score, major bleeding remained as a predictor of in-hospital death (OR = 3.34; 95% CI = 1.2-9.5; P = 0.02). Of the 29 patients who experienced bleeding, six died. However, the detailed analysis of the sequence of events showed causal relationship only in one case. CONCLUSION: (1) Major bleeding is an independent predictor of in-hospital death in ACS; (2) the role of bleeding as a risk marker overcomes that as a risk factor for death. This conclusion should be seen as a hypothesis generator to be confirmed by larger-sample studies.

Valor prognóstico da troponina I de alta sensibilidade versus troponina T nas síndromes coronarianas agudas / Prognostic value of high-sensitivity troponin I versus troponin T in acute coronary syndromes

FUNDAMENTO: Apesar da superior precisão diagnóstica das troponinas cardíacas de alta sensibilidade, seu valor prognóstico ainda não foi validado contra troponinas cardíacas convencionais. OBJETIVO: Testar o valor prognóstico da troponina I de alta sensibilidade (TnI-as) em comparação com a troponina T convencional (TnT-c) no cenário de síndromes coronarianas agudas sem supradesnivelamento do segmento ST (SCA). MÉTODOS: No momento da admissão, uma amostra de plasma foi coletada de 103 pacientes consecutivos com angina instável ou infarto agudo do miocárdio sem supradesnivelamento do segmento ST. Nessa amostra, a troponina foi medida tanto pelo método TnI-as quanto pelo método TnT-c. O valor prognóstico das duas troponinas foi comparado em relação à ocorrência de evento cardiovascular maior, definido como o composto de morte, infarto agudo do miocárdio não fatal ou angina instável refratária durante a internação. RESULTADOS: Durante uma hospitalização mediana de 8 dias (intervalo interquartil = 5-11), a incidência de eventos cardiovasculares foi 10% (5 mortes, 3 infartos não fatais e 2 anginas refratárias não fatais). Troponina I de alta sensibilidade predisse significativamente eventos cardiovasculares, com C-estatísticas de 0,73 (95% CI = 0,59-0,87), à semelhança da TnT-c (0,70; 95% CI = 0,55-0,84) - P = 0,75. A definição de troponina positiva que proporcionou melhor acurácia prognóstica foi TnI-as > 0,055 mg / L e TnT-c > 0,010 mg / L, com sensibilidade de 90% e especificidade de 52% para ambos os ensaios. CONCLUSÃO: Troponina I de alta sensibilidade prediz eventos cardiovasculares de forma semelhante à troponina T convencional no cenário de SCA. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0).

BACKGROUND: Despite superior diagnostic accuracy of high-sensitivity cardiac troponins, their prognostic value has not been validated against conventional cardiac troponins. OBJECTIVE: To test the prognostic value of high-sensitivity cardiac troponin I (hs-cTnI), compared with conventional cardiac troponin T (cTnT) in the setting of non-ST elevation acute coronary syndromes. METHODS: At hospital admission, a plasma sample was collected from 103 consecutive patients with unstable angina or non-ST elevation acute myocardial infarction. In this sample, troponin was measured both by hs-cTnI and cTnT methods. Their prognostic value was compared as to the occurrence of major cardiovascular events, defined as a combination of death, nonfatal acute myocardial infarction or refractory unstable angina during hospitalization. RESULTS: During median hospitalization of 8 days (interquartile range = 5 - 11), the incidence of cardiovascular events was 10% (5 deaths, 3 non-fatal myocardial infarctions and 2 non-fatal refractory anginas). High-sensitivity troponin I significantly predicted cardiovascular events, with a C-statistics of 0.73 (95% CI = 0.59 - 0.87), similarly to cTnT (0.70; 95% CI = 0.55 - 0.84) - P = 0.75. The definition of positive cardiac marker that provided the best prognostic accuracy was hs-cTnI > 0.055 µg/L and cTnT > 0.010 µg/L, with equal sensitivity of 90% and specificity of 52% for both assays. Positive hs-cTnI was associated with 17% incidence of events, compared with 2% in patients with negative hs-cTnI (P = 0.02). CONCLUSION: High-sensitivity troponin I predicts cardiovascular events similarly to conventional troponin T in the setting of non-ST-elevation ACS. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0).

Prognostic value of high-sensitivity troponin I versus troponin T in acute coronary syndromes.

BACKGROUND: Despite superior diagnostic accuracy of high-sensitivity cardiac troponins, their prognostic value has not been validated against conventional cardiac troponins. OBJECTIVE: To test the prognostic value of high-sensitivity cardiac troponin I (hs-cTnI), compared with conventional cardiac troponin T (cTnT) in the setting of non-ST elevation acute coronary syndromes. METHODS: At hospital admission, a plasma sample was collected from 103 consecutive patients with unstable angina or non-ST elevation acute myocardial infarction. In this sample, troponin was measured both by hs-cTnI and cTnT methods. Their prognostic value was compared as to the occurrence of major cardiovascular events, defined as a combination of death, nonfatal acute myocardial infarction or refractory unstable angina during hospitalization. RESULTS: During median hospitalization of 8 days (interquartile range = 5 - 11), the incidence of cardiovascular events was 10% (5 deaths, 3 non-fatal myocardial infarctions and 2 non-fatal refractory anginas). High-sensitivity troponin I significantly predicted cardiovascular events, with a C-statistics of 0.73 (95% CI = 0.59 - 0.87), similarly to cTnT (0.70; 95% CI = 0.55 - 0.84) - P = 0.75. The definition of positive cardiac marker that provided the best prognostic accuracy was hs-cTnI > 0.055 µg/L and cTnT > 0.010 µg/L, with equal sensitivity of 90% and specificity of 52% for both assays. Positive hs-cTnI was associated with 17% incidence of events, compared with 2% in patients with negative hs-cTnI (P = 0.02). CONCLUSION: High-sensitivity troponin I predicts cardiovascular events similarly to conventional troponin T in the setting of non-ST-elevation ACS.