Nomogram and Validity of a Model for Predicting Malnutrition in Patients on Liver Transplant Lists.

BACKGROUND: Malnutrition is associated with increased morbimortality in liver transplant patients, and it is important to identify factors related to nutritional status in these patients. AIMS: Determine variables associated with malnutrition and create a nomogram in liver transplant candidates. METHODS: Cross-sectional study (n = 110). VARIABLES: demographic variables, imbalances due to the disease, transplant aetiology and analytical parameters. Physical examination was performed and degree of hepatic dysfunction calculated. Nutritional status was assessed: Controlling Nutritional Status, Spanish Society of Parenteral and Enteral Nutrition criteria, Nutritional Risk Index, Prognostic Nutritional Index or Onodera Index and The Subjective Global Assessment. Logistic regression analysis was performed. A predictive nomogram (discrimination and calibration analysis) was generated. RESULTS: Malnourishment was defined according to at least 4 or more of the methods studied. Patients with ascites, encephalopathy and portal hypertension presented malnourishment more frequently. Malnutrition was associated with greater liver dysfunction and lower grip strength. Variables independently associated with malnourishment were encephalopathy and lower albumin values. A nomogram was created to predict malnourishment, with good discriminatory power and calibration. CONCLUSIONS: A score was developed for evaluating malnutrition risk. This would provide a tool that makes it possible to quickly and easily identify the risk of malnutrition in liver transplant candidates.

Variability between Clarke's angle and Chippaux-Smirak index for the diagnosis of flat feet.

BACKGROUND: The measurements used in diagnosing biomechanical pathologies vary greatly. The aim of this study was to determine the concordance between Clarke's angle and Chippaux-Smirak index, and to determine the validity of Clarke's angle using the Chippaux-Smirak index as a reference. METHODS: Observational study in a random population sample (n= 1,002) in A Coruña (Spain). After informed patient consent and ethical review approval, a study was conducted of anthropometric variables, Charlson comorbidity score, and podiatric examination (Clarke's angle and Chippaux-Smirak index). Descriptive analysis and multivariate logistic regression were performed. RESULTS: The prevalence of flat feet, using a podoscope, was 19.0% for the left foot and 18.9% for the right foot, increasing with age. The prevalence of flat feet according to the Chippaux-Smirak index or Clarke's angle increases significantly, reaching 62.0% and 29.7% respectively. The concordance (kappa I) between the indices according to age groups varied between 0.25-0.33 (left foot) and 0.21-0.30 (right foot). The intraclass correlation coefficient (ICC) between the Chippaux-Smirak index and Clarke's angle was -0.445 (left foot) and -0.424 (right foot). After adjusting for age, body mass index (BMI), comorbidity score and gender, the only variable with an independent effect to predict discordance was the BMI (OR= 0.969; 95% CI: 0.940-0.998). CONCLUSION: There is little concordance between the indices studied for the purpose of diagnosing foot arch pathologies. In turn, Clarke's angle has a limited sensitivity in diagnosing flat feet, using the Chippaux-Smirak index as a reference. This discordance decreases with higher BMI values.

INTRODUCCIÓN: Existe una gran variabilidad en las mediciones para el diagnóstico de la patología biomecánica. El objetivo de este estudio fue determinar la concordancia entre el ángulo de Clarke y el índice de Chippaux-Smirak, para determinar la validez del ángulo de Clarke utilizando como referencia el índice de Chippaux-Smirak. MÉTODOS: Se realizó un estudio observacional en una muestra aleatoriamente seleccionada (n=1,002) en A Coruña (España). Tras el consentimiento informado del paciente y la aprobación del comité de ética, se estudiaron variables, antropométricas, índice de comorbilidad de Charlson y un examen podológico (ángulo de Clarke, índice de Chippaux-Smirak). Se realizó un estudio descriptivo y un análisis multivariado de regresión logística. RESULTADOS: La prevalencia de pie plano utilizando el podoscopio fue de 19.0% (pie izquierdo) y 18.9% (pie derecho), incrementándose con la edad.La prevalencia de pie plano según el índice Chippaux-Smirak o el ángulo de Clarke se incrementan considerablemente llegando a 62.0% y 29.7%.La concordancia (kappa I) entre los índices según grupos de edad oscila entre 0.25-0.33 (pie izquierdo) y 0.21-0.30 (pie derecho). El coeficiente de correlación intraclase (CCI) entre el índice de Chippaux-Smirak y el ángulo de Clarke es -0.445 (pie izquierdo) y 0.424 (pie derecho). Tras ajustar por edad, índice de masa corporal (IMC), score de comorbilidad y sexo la única variable con un efecto independiente para predecir discordancia es el IMC (OR= 0.969; IC 95%: 0.940-0.998). CONCLUSIONES: La concordancia entre los índices estudiados para el diagnóstico de la patología del arco plantar es reducida. Existe a su vez una reducida sensibilidad del ángulo de Clarke para el diagnóstico de pie plano, utilizando como referencia el índice de Chippaux-Smirak. Esta discordancia disminuye con valores más altos de IMC.

Concordance among methods of nutritional assessment in patients included on the waiting list for liver transplantation.

BACKGROUND: The aim of the present study was to determine the extent of malnutrition in patients waiting for a liver transplant. The agreement among the methods of nutritional assessment and their diagnostic validity were evaluated. METHODS: Patients on the waiting list for liver transplantation (n = 110) were studied. The variables were: body mass index, analytical parameters, liver disease etiology, and complications. Liver dysfunction was evaluated using the Child-Pugh Scale. Nutritional state was studied using the Controlling Nutritional Status (CONUT), the Spanish Society of Parenteral and Enteral Nutrition (SENPE) criteria, the Nutritional Risk Index (NRI), the Prognostic Nutritional Index (PNI-O), and the Subjective Global Assessment (SGA). Agreement was determined using the Kappa index. Area under receiver operator characteristic curves (AUCs), the Youden index (J), and likelihood ratios were computed. RESULTS: Malnutrition varied depending on the method of evaluation. The highest value was detected using the CONUT (90.9%) and the lowest using the SGA (50.9%). The pairwise agreement among the methods ranged from K = 0.041 to K = 0.826, with an overall agreement of each criteria with the remaining methods between K = 0.093 and K = 0.364. PNI-O was the method with the highest overall agreement. Taking this level of agreement into account, we chose the PNI-O as a benchmark method of comparison. The highest positive likelihood ratio for the diagnosis of malnutrition was obtained from the Nutritional Risk Index (13.56). CONCLUSIONS: Malnutrition prevalence is high and prevalence estimates vary according the method used, with low concordance among methods. PNI-O and NRI are the most consistent methods to identify malnutrition in these patients.

How in-office and ambulatory BP monitoring compare: A systematic review and meta-analysis.

Purpose: We performed a literature review and meta-analysis to ascertain the validity of office blood pressure (BP) measurement in a primary care setting, using ambulatory blood pressure measurement (ABPM) as a benchmark in the monitoring of hypertensive patients receiving treatment. Methods: We conducted a literature search for studies published up to December 2013 that included hypertensive patients receiving treatment in a primary care setting. We compared the mean office BP with readings obtained by ABPM. We summarized the diagnostic accuracy of office BP with respect to ABPM in terms of sensitivity, specificity, and positive and negative likelihood ratios (LR), with a 95% confidence interval (CI). Results: Only 12 studies met the inclusion criteria and contained data to calculate the differences between the means of office and ambulatory BP measurements. Five were suitable for calculating sensitivity, specificity, and likelihood ratios, and 4 contained sufficient extractable data for meta-analysis. Compared with ABPM (thresholds of 140/90 mm Hg for office BP; 130/80 mmHg for ABPM) in diagnosing uncontrolled BP, office BP measurement had a sensitivity of 81.9% (95% CI, 74.8%-87%) and specificity of 41.1% (95% CI, 35.1%-48.4%). Positive LR was 1.35 (95% CI, 1.32-1.38), and the negative LR was 0.44 (95% CI, 0.37-0.53). Conclusion: Likelihood ratios show that isolated BP measurement in the office does not confirm or rule out the presence of poor BP control. Likelihood of underestimating or overestimating BP control is high when relying on in-office BP measurement alone.

Variability between Clarke's angle and Chippaux-Smirak index for the diagnosis of flat feet / Variabilidad entre el ángulo de Clarke y el índice de Chippaux- Smirak para el diagnóstico de pie plano

Abstract Background: The measurements used in diagnosing biomechanical pathologies vary greatly. The aim of this study was to determine the concordance between Clarke's angle and Chippaux-Smirak index, and to determine the validity of Clarke's angle using the Chippaux-Smirak index as a reference. Methods: Observational study in a random population sample (n= 1,002) in A Coruña (Spain). After informed patient consent and ethical review approval, a study was conducted of anthropometric variables, Charlson comorbidity score, and podiatric examination (Clarke's angle and Chippaux-Smirak index). Descriptive analysis and multivariate logistic regression were performed. Results: The prevalence of flat feet, using a podoscope, was 19.0% for the left foot and 18.9% for the right foot, increasing with age. The prevalence of flat feet according to the Chippaux-Smirak index or Clarke's angle increases significantly, reaching 62.0% and 29.7% respectively. The concordance (kappa I) between the indices according to age groups varied between 0.25-0.33 (left foot) and 0.21-0.30 (right foot). The intraclass correlation coefficient (ICC) between the Chippaux-Smirak index and Clarke's angle was -0.445 (left foot) and -0.424 (right foot). After adjusting for age, body mass index (BMI), comorbidity score and gender, the only variable with an independent effect to predict discordance was the BMI (OR= 0.969; 95% CI: 0.940-0.998). Conclusion: There is little concordance between the indices studied for the purpose of diagnosing foot arch pathologies. In turn, Clarke's angle has a limited sensitivity in diagnosing flat feet, using the Chippaux-Smirak index as a reference. This discordance decreases with higher BMI values.

Resumen Introducción: Existe una gran variabilidad en las mediciones para el diagnóstico de la patología biomecánica. El objetivo de este estudio fue determinar la concordancia entre el ángulo de Clarke y el índice de Chippaux-Smirak, para determinar la validez del ángulo de Clarke utilizando como referencia el índice de Chippaux-Smirak. Métodos: Se realizó un estudio observacional en una muestra aleatoriamente seleccionada (n= 1,002) en A Coruña (España). Tras el consentimiento informado del paciente y la aprobación del comité de ética, se estudiaron variables, antropométricas, índice de comorbilidad de Charlson y un examen podológico (ángulo de Clarke, índice de Chippaux-Smirak). Se realizó un estudio descriptivo y un análisis multivariado de regresión logística. Resultados: La prevalencia de pie plano utilizando el podoscopio fue de 19.0% (pie izquierdo) y 18.9% (pie derecho), incrementándose con la edad. La prevalencia de pie plano según el índice Chippaux-Smirak o el ángulo de Clarke se incrementan considerablemente llegando a 62.0% y 29.7%. La concordancia (kappa I) entre los índices según grupos de edad oscila entre 0.25-0.33 (pie izquierdo) y 0.21-0.30 (pie derecho). El coeficiente de correlación intraclase (CCI) entre el índice de Chippaux-Smirak y el ángulo de Clarke es -0.445 (pie izquierdo) y 0.424 (pie derecho). Tras ajustar por edad, índice de masa corporal (IMC), score de comorbilidad y sexo la única variable con un efecto independiente para predecir discordancia es el IMC (OR= 0.969; IC 95%: 0.940-0.998). Conclusiones: La concordancia entre los índices estudiados para el diagnóstico de la patología del arco plantar es reducida. Existe a su vez una reducida sensibilidad del ángulo de Clarke para el diagnóstico de pie plano, utilizando como referencia el índice de Chippaux-Smirak. Esta discordancia disminuye con valores más altos de IMC.

Effect of diagnostic delay on survival in patients with colorectal cancer: a retrospective cohort study.

BACKGROUND: Disparate and contradictory results make studies necessary to investigate in more depth the relationship between diagnostic delay and survival in colorectal cancer (CRC) patients. The aim of this study is to analyse the relationship between the interval from first symptom to diagnosis (SDI) and survival in CRC. METHODS: Retrospective study of n = 942 CRC patients. SDI was calculated as the time from the diagnosis of cancer and the first symptoms of CRC. Cox regression was used to estimate five-year mortality hazard ratios as a function of SDI, adjusting for age and gender. SDI was modelled according to SDI quartiles and as a continuous variable using penalized splines. RESULTS: Median SDI was 3.4 months. SDI was not associated with stage at diagnosis (Stage I = 3.6 months, Stage II-III = 3.4, Stage IV = 3.2; p = 0.728). Shorter SDIs corresponded to patients with abdominal pain (2.8 months), and longer SDIs to patients with muchorrhage (5.2 months) and rectal tenesmus (4.4 months). Adjusting for age and gender, in rectum cancers, patients within the first SDI quartile had lower survival (p = 0.003), while in colon cancer no significant differences were found (p = 0.282). These results do not change after adjusting for TNM stage. The splines regression analysis revealed that, for rectum cancer, 5-year mortality progressively increases for SDIs lower than the median (3.7 months) and decreases as the delay increases until approximately 8 months. In colon cancer, no significant relationship was found between SDI and survival. CONCLUSIONS: Short diagnostic intervals are significantly associated with higher mortality in rectal but not in colon cancers, even though a borderline significant effect is also observed in colon cancer. Longer diagnostic intervals seemed not to be associated with poorer survival. Other factors than diagnostic delay should be taken into account to explain this "waiting-time paradox".

Radioterapia axilar en la cirugía conservadora del cáncer de mama en estadio temprano (estadio I y II) / Axillary radiotherapy in conservative surgery for early-stage breast cancer (stage I and II)

INTRODUCCIÓN: Diversos estudios clínicos analizan el tratamiento axilar en el cáncer de mama temprano debido a los cambios actuales en la indicación de la linfadenectomía axilar. El objetivo de este estudio fue analizar el impacto de la radioterapia axilar en la supervivencia global y libre de enfermedad en mujeres con un carcinoma de mama en estadio inicial tratadas mediante cirugía conservadora. MÉTODOS: Estudio retrospectivo en mujeres con un carcinoma infiltrante de mama en estadios iniciales tratadas mediante cirugía conservadora. Análisis comparativo de las mujeres con afectación ganglionar y factores de riesgo asociados que recibieron radioterapia axilar frente a un grupo con afectación ganglionar de bajo riesgo sin tratamiento radioterápico. Se utilizó una regresión logística para determinar los factores que influían en la supervivencia y en la aparición de linfedema. RESULTADOS: Se incluyó a 541 mujeres, 384 (71%) sin afectación de ganglios linfáticos axilares y 157 (29%) con afectación de 1-3 ganglios axilares. Las pacientes con radioterapia axilar tenían un mayor número de ganglios metastásicos respecto a las no irradiadas (1,6 ± 0,7 vs. 1,4 ± 0,6; p = 0,02). El grupo de mujeres con afectación ganglionar y radioterapia axilar tuvo una supervivencia global y libre de enfermedad a los 10 años similar a las pacientes sin irradiación de la axila (89,7 y 77,2%, respectivamente). La afectación de 3 ganglios incrementó 7 veces el riesgo de fallecer (HR = 7,20; IC 95%: 1,36-38,12). En el estudio multivariante, la linfadenectomía axilar fue el único factor de riesgo independiente de aparición de linfedema (HR = 22,22; IC 95%: 4,71-105,59; p < 0,001). CONCLUSIÓN: La recidiva axilar en el cáncer de mama en estadios I y II es un evento poco frecuente. En las enfermas con afectación axilar y factores de riesgo asociados, la radioterapia regional contribuye al control locorregional de la enfermedad con igual supervivencia global

INTRODUCTION: Several clinical studies analyze axillary treatment in women with early-stage breast cancer because of changes in the indication for axillary lymph node dissection. The aim of the study is to analyze the impact of axillary radiotherapy in disease-free and overall survival in women with early breast cancer treated with lumpectomy. METHODS: Retrospective study in women with initial stages of breast carcinoma treated by lumpectomy. A comparative analysis of high-risk women with axillary lymph node involvement who received axillary radiotherapy with the group of women with low risk without radiotherapy was performed. Logistic regression was used to determine factors influencing survival and lymphedema onset. RESULTS: A total of 541 women were included in the study: 384 patients (71%) without axillary lymph node involvement and 157 women (29%) with 1-3 axillary lymph node involvement. Patients with axillary radiotherapy had a higher number of metastatic lymph node compared to non-irradiated (1.6 ± 0.7 vs. 1.4 ± 0.6, P=.02). The group of women with axillary lymph node involvement and radiotherapy showed an overall and disease-free survival at 10 years similar to that obtained in patients without irradiation (89.7% and 77.2%, respectively). 3 lymph nodes involved multiplied by more than 7 times the risk of death (HR = 7.20; 95% CI: 1.36 to 38.12). The multivariate analysis showed axillary lymph node dissection as the only variable associated with the development of lymphedema. CONCLUSION: The incidence of axillary relapse on stage I and II breast cancer is rare. In these patients axillary radiotherapy does not improve overall survival, but contributes to regional control in those patients with risk factors

Axillary radiotherapy in conservative surgery for early-stage breast cancer (stage I and II). / Radioterapia axilar en la cirugía conservadora del cáncer de mama en estadio temprano (estadio I y II).

INTRODUCTION: Several clinical studies analyze axillary treatment in women with early-stage breast cancer because of changes in the indication for axillary lymph node dissection. The aim of the study is to analyze the impact of axillary radiotherapy in disease-free and overall survival in women with early breast cancer treated with lumpectomy. METHODS: Retrospective study in women with initial stages of breast carcinoma treated by lumpectomy. A comparative analysis of high-risk women with axillary lymph node involvement who received axillary radiotherapy with the group of women with low risk without radiotherapy was performed. Logistic regression was used to determine factors influencing survival and lymphedema onset. RESULTS: A total of 541 women were included in the study: 384 patients (71%) without axillary lymph node involvement and 157 women (29%) with 1-3 axillary lymph node involvement. Patients with axillary radiotherapy had a higher number of metastatic lymph node compared to non-irradiated (1.6±0.7 vs. 1.4±0.6, P=.02). The group of women with axillary lymph node involvement and radiotherapy showed an overall and disease-free survival at 10 years similar to that obtained in patients without irradiation (89.7% and 77.2%, respectively). 3 lymph nodes involved multiplied by more than 7 times the risk of death (HR=7.20; 95% CI: 1.36 to 38.12). The multivariate analysis showed axillary lymph node dissection as the only variable associated with the development of lymphedema. CONCLUSION: The incidence of axillary relapse on stage I and II breast cancer is rare. In these patients axillary radiotherapy does not improve overall survival, but contributes to regional control in those patients with risk factors.

A randomised crossover trial comparing the Airtraq ® NT, McGrath ® MAC and Macintosh laryngoscopes for nasotracheal intubation of simulated easy and difficult airways in a manikin / Estudo cruzado e randômico comparando os laringoscópios Airtraq ® NT, McGrath ® MAC e Macintosh para intubação nasotraqueal em simulação de via aérea fácil e difícil em manequim

ABSTRACT OBJECTIVE: Several devices can aid nasotracheal intubation when managing difficult airways. The McGrath MAC and Airtraq NT were compared with a Macintosh laryngoscope when studying the performance of anaesthetists with different levels of experience, in a manikin model of easy or difficult airway scenarios. METHODS: Sixty-three anaesthetists were recruited into a randomised trial in which each performed nasotracheal intubation with all laryngoscopes, in both scenarios. The main endpoint was intubation time. Additional endpoints included laryngoscopic view, intubation success, number of optimisation manoeuvres, audible dental clicks and the force applied to the upper airway. RESULTS: Intubation time was significantly shorter using the McGrath MAC in both scenarios and using the Airtraq in the difficult scenario, when compared with the Macintosh laryngoscope. Both devices gave more Cormack and Lehane grade 1 or 2 views than the Macintosh in the difficult scenario (p < 0.001). The McGrath MAC had the best first-attempt success rate (98.4% vs. 96.8% and 95.8%, p < 0.001 for the Airtraq NT and Macintosh laryngoscopes respectively). The number of optimisation manoeuvres, audible dental clicks and subjective assessment of the degree of force applied were significantly lower for indirect laryngoscopes versus the Macintosh laryngoscope (p < 0.001). CONCLUSION: In a manikin, the Airtraq and the McGrath laryngoscopes appeared superior to the Macintosh laryngoscope when dealing with simulated airway scenarios. Both devices were associated with better views, intubation times and rates of success, especially in a simulated "difficult airway". Overall satisfaction was highest with the McGrath laryngoscope. Similar clinical studies are needed.

RESUMO OBJETIVO: Vários dispositivos podem ajudar a intubação nasotraqueal no manejo de via aérea difícil. Os laringoscópios McGrath MAC e Airtraq NT foram comparados com um laringoscópio Macintosh em estudo do desempenho de anestesistas com diferentes níveis de experiência, em manequim com cenário de via aérea fácil ou difícil. MÉTODOS: Foram recrutados 63 anestesistas para um estudo randômico, no qual cada um fez intubação nasotraqueal com todos os laringoscópios, em ambos os cenários. O desfecho primário foi o tempo de intubação. Desfechos adicionais incluíram vista laringoscópica, sucesso na intubação, número de manobras de aprimoramento, cliques dentais audíveis e força aplicada nas vias aéreas superiores. RESULTADOS: O tempo de intubação foi significativamente menor com o uso do laringoscópio McGrath MAC em ambos os cenários e com o uso do Airtraq no cenário difícil, em comparação com o laringoscópio Macintosh. Ambos os dispositivos obtiveram mais grau 1 ou 2 de Cormack e Lehane para visualização do que o Macintosh em cenário difícil (p < 0,001). O McGrath MAC teve a melhor taxa de sucesso na primeira tentativa (98,4% vs. 96,8% e 95,8%, p < 0,001, para os laringoscópios Airtraq NT e Macintosh, respectivamente). O número de manobras de aprimoramento, os cliques dentais audíveis e a avaliação subjetiva do grau de força aplicada foram significativamente menores para os laringoscópios indiretos versus o laringoscópio Macintosh (p < 0,001). CONCLUSÃO: Em um manequim, os laringoscópios Airtraq e McGrath pareceram superiores ao laringoscópio Macintosh para lidar com cenários das vias aéreas simuladas. Ambos os dispositivos foram associados a melhores visibilidades, tempos de intubação e taxas de sucesso, especialmente em simulação de "via aérea difícil". A satisfação geral foi maior com o laringoscópio McGrath. Estudos clínicos similares são necessários.

A randomized clinical trial to determine the effectiveness of CO-oximetry and anti-smoking brief advice in a cohort of kidney transplant patients who smoke: study protocol for a randomized controlled trial.

BACKGROUND: The cardiovascular risk in renal transplant patients is increased in patients who continue to smoke after transplantation. The aim of the study is to measure the effectiveness of exhaled carbon monoxide (CO) measurement plus brief advisory sessions, in comparison to brief advice, to reduce smoking exposure and smoking behavior in kidney transplant recipients who smoke. The effectiveness will be measured by: (1) abandonment of smoking, (2) increase in motivation to stop smoking, and (3) reduction in the number of cigarettes smoked per day. DESIGN: a randomized, controlled, open clinical trial with blinded evaluation. SCOPE: A Coruña Hospital (Spain), reference to renal transplantation in the period 2012-2015. INCLUSION CRITERIA: renal transplant patients who smoke in the precontemplation, contemplation or preparation stages according to the Prochaska and DiClemente's Stages of Change model, and who give their consent to participate. EXCLUSION CRITERIA: smokers attempting to stop smoking, patients with terminal illness or mental disability that prevents them from participating. RANDOMIZATION: patients will be randomized to the control group (brief advisory session) or the intervention group (brief advisory session plus measuring exhaled CO). The sample target size is n = 112, with 56 patients in each group. Allowing for up to 10 % loss to follow-up, this would provide 80 % power to detect a 13 % difference in attempting to give up smoking outcomes at a two-tailed significance level of 5 %. MEASUREMENTS: sociodemographic characteristics, cardiovascular risk factors, treatment, rejection episodes, infections, self-reported smoking habit, drug use, level of dependence (the Fagerström test), stage of change (Prochaska and DiClemente's Stages of Change model), and motivation to giving up smoking (the Richmond test). RESPONSE: the effectiveness will be evaluated every 3, 6, 9 and 12 months as: pattern of tobacco use (self-reported tobacco use), smoking cessation rates, carbon monoxide (CO) levels in exhaled air measured by CO-oximetry, urinary cotinine tests, nicotine dependence (Fagerström test), motivational stages of change (Prochaska and DiClemente's stages) and motivation to stop smoking (the Richmond test). ANALYSIS: descriptive statistics and linear/logistic multiple regression models will be performed. Clinical relevance will be measured as relative risk reduction, absolute risk reduction and the number needed to treat. ETHICS: informed consent of the patients and Ethical Review Board was obtained (code 2011/061). DISCUSSION: Tobacco is a modifiable risk factor that increase the risk of morbidity and mortality in kidney transplant recipients. If effectiveness of CO-oximetry is confirmed to reduce tobacco exposure, we would have an intervention that is easy to use, low cost and with great implications about cardiovascular risk prevention in these patients. TRIAL REGISTRATION: Current Controlled Trials ISRCTN16615772 . EudraCT number: 2015-002009-12.

A randomised crossover trial comparing the Airtraq(®) NT, McGrath(®) MAC and Macintosh laryngoscopes for nasotracheal intubation of simulated easy and difficult airways in a manikin.

OBJECTIVE: Several devices can aid nasotracheal intubation when managing difficult airways. The McGrath MAC and Airtraq NT were compared with a Macintosh laryngoscope when studying the performance of anaesthetists with different levels of experience, in a manikin model of easy or difficult airway scenarios. METHODS: Sixty-three anaesthetists were recruited into a randomised trial in which each performed nasotracheal intubation with all laryngoscopes, in both scenarios. The main endpoint was intubation time. Additional endpoints included laryngoscopic view, intubation success, number of optimisation manoeuvres, audible dental clicks and the force applied to the upper airway. RESULTS: Intubation time was significantly shorter using the McGrath MAC in both scenarios and using the Airtraq in the difficult scenario, when compared with the Macintosh laryngoscope. Both devices gave more Cormack and Lehane grade 1 or 2 views than the Macintosh in the difficult scenario (p<0.001). The McGrath MAC had the best first-attempt success rate (98.4% vs. 96.8% and 95.8%, p<0.001 for the Airtraq NT and Macintosh laryngoscopes respectively). The number of optimisation manoeuvres, audible dental clicks and subjective assessment of the degree of force applied were significantly lower for indirect laryngoscopes versus the Macintosh laryngoscope (p<0.001). CONCLUSION: In a manikin, the Airtraq and the McGrath laryngoscopes appeared superior to the Macintosh laryngoscope when dealing with simulated airway scenarios. Both devices were associated with better views, intubation times and rates of success, especially in a simulated "difficult airway". Overall satisfaction was highest with the McGrath laryngoscope. Similar clinical studies are needed.

[A randomised crossover trial comparing the Airtraq(®) NT, McGrath(®) MAC and Macintosh laryngoscopes for nasotracheal intubation of simulated easy and difficult airways in a manikin]. / Estudo cruzado e randômico comparando os laringoscópios Airtraq(®) NT, McGrath(®) MAC e Macintosh para intubação nasotraqueal em simulação de via aérea fácil e difícil em manequim.

OBJECTIVE: Several devices can aid nasotracheal intubation when managing difficult airways. The McGrath MAC and Airtraq NT were compared with a Macintosh laryngoscope when studying the performance of anaesthetists with different levels of experience, in a manikin model of easy or difficult airway scenarios. METHODS: Sixty-three anaesthetists were recruited into a randomised trial in which each performed nasotracheal intubation with all laryngoscopes, in both scenarios. The main endpoint was intubation time. Additional endpoints included laryngoscopic view, intubation success, number of optimisation manoeuvres, audible dental clicks and the force applied to the upper airway. RESULTS: Intubation time was significantly shorter using the McGrath MAC in both scenarios and using the Airtraq in the difficult scenario, when compared with the Macintosh laryngoscope. Both devices gave more Cormack and Lehane grade 1 or 2 views than the Macintosh in the difficult scenario (p<0.001). The McGrath MAC had the best first-attempt success rate (98.4% vs. 96.8% and 95.8%, p<0.001 for the Airtraq NT and Macintosh laryngoscopes respectively). The number of optimisation manoeuvres, audible dental clicks and subjective assessment of the degree of force applied were significantly lower for indirect laryngoscopes versus the Macintosh laryngoscope (p<0.001). CONCLUSION: In a manikin, the Airtraq and the McGrath laryngoscopes appeared superior to the Macintosh laryngoscope when dealing with simulated airway scenarios. Both devices were associated with better views, intubation times and rates of success, especially in a simulated "difficult airway". Overall satisfaction was highest with the McGrath laryngoscope. Similar clinical studies are needed.

Inhibition of Gastric Acid Secretion by H2 Receptor Antagonists Associates a Definite Risk of Enteric Peritonitis and Infectious Mortality in Patients Treated with Peritoneal Dialysis.

BACKGROUND: Evidences linking treatment with inhibitors of gastric acid secretion (IGAS) and an increased risk of serious infections are inconclusive, both in the population at large and in the particular case of patients with chronic kidney disease. We have undertaken an investigation to disclose associations between treatment with IGAS and infectious outcomes, in patients undergoing chronic Peritoneal Dialysis (PD). METHOD: Observational, historic cohort, single center design. Six hundred and ninety-one patients incident on PD were scrutinized for an association among treatment with IGAS (H2 antagonists H2A or proton pump inhibitors PPI) (main study variable), on one side, and the risks of enteric peritoneal infection (main outcome), overall peritoneal infection, and general and infectious mortality (secondary outcomes). We applied a three-step multivariate approach, based on classic Cox models (baseline variables), time-dependent analyses and, when appropriate, competing risk analyses. MAIN RESULTS: The clinical characteristics of patients treated with H2A, PPI or none of these were significantly different. Multivariate analyses disclosed a consistently increased risk of enteric peritonitis in patients treated with IGAS (RR 1.65, 95% CI 1.08-2.55, p = 0.018, Cox). Stratified analysis indicated that patients treated with H2A, rather than those on PPI, supported the burden of this risk. Similar findings applied for the risk of infectious mortality. On the contrary, we were not able to detect any association among the study variables, on one side, and the general risks of peritonitis or mortality, on the other. CONCLUSIONS: Treatment with IGAS associates increased incidences of enteric peritonitis and infectious mortality, among patients on chronic PD. The association is clear in the case of H2A but less consistent in the case of PPI. Our results support the convenience of preferring PPI to H2A, for gastric acid inhibition in PD patients.

Identification of Targets for Prevention of Peritoneal Catheter Tunnel and Exit-Site Infections in Low Incidence Settings.

UNLABELLED: ♦ BACKGROUND: Peritoneal catheter tunnel and exit-site infection (TESI) complicates the clinical course of peritoneal dialysis (PD) patients. Adherence to recommendations for catheter insertion, exit-site care, and management of Staphylococcus aureus (SAu) carriage reduces, but does not abrogate the risk of these infections. ♦ OBJECTIVE: To reappraise the risk profile for TESI in an experienced center with a long-term focus on management of SAu carriage and a low incidence of these infections. ♦ METHOD: Following a retrospective, observational design, we investigated 665 patients incident on PD. The main study variable was survival to the first episode of TESI. We considered selected demographic, clinical, and technical variables, applying multivariate strategies of analysis. ♦ MAIN RESULTS: The overall incidence of TESI was 1 episode/68.5 patient-months. Staphylococcus aureus carriage disclosed at inception of PD (but not if observed sporadically during follow-up) (hazard ratio [HR] 1.53, p = 0.009), PD started shortly after catheter insertion (HR 0.98 per day, p = 0.011), PD after kidney transplant failure (HR 2.18, p = 0.017), lower hemoglobin levels (HR 0.88 per g/dL, p = 0.013) and fast peritoneal transport rates (HR 2.92, p = 0.03) portended an increased risk of TESI. Delaying PD ≥ 30 days after catheter insertion markedly improved the probability of TESI. Carriage of methicillin-resistant SAu since the start of PD was associated with a high incidence of TESI by these bacteria. On the contrary, resistance to mupirocin did not predict such a risk, probably due to the use of an alternative regime in affected patients. ♦ CONCLUSIONS: Adherence to current recommendations results in a low incidence of TESI in PD patients. Interventions on specific risk subsets have a potential to bring incidence close to negligible levels. Despite systematic screening and management, SAu carriage is still a predictor of TESI. Antibiotic susceptibility patterns may help to refine stratification of the risk of TESI by these bacteria. Early insertion of the peritoneal catheter should be considered whenever possible, to reduce the risk of later TESI.

Comorbidity as a predictor of mortality and mobility after hip fracture.

AIM: To determine mortality and mobility rates after hip fracture. METHODS: A prospective study (n = 199 patients) was carried out in the Health Care Center of A Coruña (Spain) during the period between January 2009 and December 2011. A descriptive study, and Cox and logistic regression analysis were carried out. Informed consent and ethical review board approval were obtained (code 2010/120 CEIC Galicia). RESULTS: The patients' mean age was 82.5 ± 8.4 years and 76% were female. The average Charlson Comorbidity Index score was 6.1 ± 2.1. Creatinine clearance <60 mL/min/1.73 m(2) was 44%. The probability of survival 6 months after hip fracture was 89.2% and the survival rate at 12 months was 81.4%. Cox regression analysis showed that the indicator that most influenced mortality rate was comorbidity (HR = 1.133; P = 0.020) and age approaching borderline statistical significance (HR = 1.034; P = 0.064). The Parker Mobility Score decreased significantly (P < 0.001) after hip fracture. Before fracture, 19% of the patients were able to get about the house, 26% were able to get out of the house and 55% were able to go shopping. After hip fracture (90 days), the percentages changed to 56.2%, 19.1% and 24.7%, respectively (P < 0.001). After taking into account age, sex, type of fracture, surgical delay, previous fracture and comorbidity, the only indicator capable of predicting incapacity to walk was comorbidity. CONCLUSIONS: Comorbidity is the best predictor of mortality and mobility after hip fracture. Geriatr Gerontol Int 2016; 16: 561-569.

[Prognostic factors in adult patients hospitalized for pneumonia caused by Legionella pneumophila]. / Factores pronósticos en adultos hospitalizados por neumonía causada por Legionella pneumophila.

INTRODUCTION: Legionellosis is a multisystem bacterial disease, which causes pneumonia with high mortality in patients with comorbidity and admitted in intensive care units (ICU). OBJECTIVE: Determine predictors of mortality or ICU admission. METHODS: Retrospective follow-up of patients diagnosed with Legionella pneumophila pneumonia in Complexo Hospitalario Universitario de A Coruña. Period 2000-2013 (n=240). Analysis of multivariate logistic regression was performed. RESULTS: Mean age was 57.2±15.4 years old, 88.3% were male. Average score of comorbidity (Charlson score) was 2.3±2.3. There was a clear seasonal variation. Predominant symptoms were fever (92.5%), dry cough (38.1%) and dyspnea (33.9%). Creatinine clearance was lower than 60 mL/min/1.73 m² in 29.7% and sodium<135 mEq/l in 58.3%. Admission to ICU rate was 16.3% and 10.8% needs mechanical ventilation. Inhospital mortality rate was 4.6%, rising to 23.1% in patients admitted to ICU. Variables associated to predict ICU admission were age (OR=0.96), liver disease (OR=7.13), dyspnea (OR=4.33), delirium (OR=5.86) and high levels of lactatedehydrogenase (OR=1.002). Variables associated with inhospital mortality were Charlson index (OR=1.70), mechanical ventilation (OR=31.44) and high levels of lactatedehydrogenase (OR=1.002). DISCUSSION: Younger patients with liver disease, dyspnea and confusion are more likely to be admitted to ICU. Comorbidity, mechanical ventilation and elevated LDH levels are associated with higher mortality rate.

Characteristics and pattern of recurrence after curative surgery in oesophageal cancer.

BACKGROUND AND AIM: Recurrence in oesophageal cancer continues to remain high after curative surgery. The aim of this study was to determine the presence of recurrence after curative surgery during follow-up, and the associated variables. METHODS: A retrospective and prospective follow-up study in patients with an anatomical-pathological diagnosis of oesophageal cancer who underwent curative surgery (n = 57) in the health district of A Coruña (Spain) during the period 2003-2008. The calculation of recurrence-free survival was made using a competing risks survival analysis. RESULTS: Out of the 57 patients included in the study, 87.7% were men with a mean age of 61.4 ± 10.3 years. The median follow-up period was 18.5 months, during which 28 recurrences were detected (50.9%). Patients with dysphagia on diagnosis of the disease, as well as patients in stages III-IV, have a higher probability of recurrence during the follow-up period. The median disease-free interval was 8.5 months. After one year of follow up, 57.1% of the recurrences were diagnosed and 82.1% after 2 years of followup. The median post-recurrence survival rate was 4.7 months. After adjusting for a multivariate regression model, the variable with an independent effect for predicting recurrence is the TNM classification (HR = 8.49). CONCLUSIONS: The majority of the recurrences will be developed during the 2 years after surgery, with a very poor prognosis. The predictor variable for recurrence is the TMN classification.

Repercusión de los criterios ACOSOG Z0011 sobre la indicación de la linfadenectomía axilar y el control locorregional en mujeres con ganglio centinela metastásico. Resultados preliminares tras cuatro años de aplicación clínica / Repercussion of the ACOSOG-Z0011 criteria for the indication of axillary lymph node dissection and locoregional control in women with metastatic sentinel lymph node. Preliminary results after four years of clinical application

Objetivo. Evaluar los cambios en la indicación de la linfadenectomía axilar (LA), su eficacia para eliminar enfermedad residual y control locorregional, tras la adopción de los criterios del estudio ACOSOG Z0011. Pacientes y método. Estudio observacional retrospectivo en mujeres con carcinoma infiltrante de mama tratadas quirúrgicamente, entre febrero 2010 y mayo de 2014. Todas las pacientes fueron valoradas según los criterios del ensayo clínico ACOSOG Z0011 para el manejo del ganglio centinela (GC) metastatizado. Resultados. Un total de 118 enfermas presentaron afectación del GC, y de ellas 53 (44,92% de las pacientes con GC metastásico) evitaron la LA por la aplicación de los criterios ACOSOG Z0011. La mayoría de estas mujeres (73,58%) presentaron afectación micrometastásica del GC. El grupo de enfermas con mayor beneficio fueron las pacientes con conservación mamaria, ya que el 58,23% de estas enfermas evitaron la LA. Se realizaron un total de 65 LA por afectación metastásica del GC sin que se evidenciase metástasis en la grasa axilar en 37 (55,2%) pacientes. Conclusiones. La adopción de los criterios ACOSOG Z0011 permite disminuir la indicación de la LA, especialmente en aquellas mujeres sometidas a un procedimiento conservador. A pesar de la introducción de estos criterios, existe un grupo significativo de mujeres (55%) en quienes la LA no demuestra afectación ganglionar de la grasa axilar y no obtienen ningún beneficio con la misma (AU)

Objective. To evaluate changes in the indication of axillary lymph node dissection (ALND), its effectiveness in eliminating residual disease, and locoregional control after the adoption of the ACOSOG Z0011 study criteria. Patients and methods. Retrospective study in women with invasive breast cancer treated surgically from February 2010 to May 2014. All women were evaluated according to the ACOSOG-Z0011 trial criteria for the management of metastasized sentinel lymph node (SLN). Results. A total of 118 women had SLN involvement. Application of the ACOSOG Z0011 criteria avoided ALND in 53 of the 118 patients (44.92% of the patients with metastatic SLN), most of them (73.58%) with micrometastases. The benefit was greater in women undergoing conservative surgery, because 58.23% of these women avoided ALND. A total of 65 ALND were performed for metastatic SLN, of which 37 (55.2%) showed no involvement of axillary fat. Conclusions. Adoption of the ACOSOG Z0011 criteria decreases the indication of ALND, especially in women undergoing conservative surgery. Despite the introduction of these criteria, there is a significant percentage of women (55%) in whom ALND shows no lymph node involvement in axillary fat and produces no benefit (AU)

Characteristics and pattern of recurrence after curative surgery in oesophageal cancer

BACKGROUND AND AIM: Recurrence in oesophageal cancer continues to remain high after curative surgery. The aim of this study was to determine the presence of recurrence after curative surgery during follow-up, and the associated variables. METHODS: A retrospective and prospective follow-up study in patients with an anatomical-pathological diagnosis of oesophageal cancer who underwent curative surgery (n = 57) in the health district of A Coruña (Spain) during the period 2003-2008. The calculation of recurrence-free survival was made using a competing risks survival analysis. RESULTS: Out of the 57 patients included in the study, 87.7% were men with a mean age of 61.4 ± 10.3 years. The median follow-up period was 18.5 months, during which 28 recurrences were detected (50.9%). Patients with dysphagia on diagnosis of the disease, as well as patients in stages III-IV, have a higher probability of recurrence during the follow-up period. The median disease-free interval was 8.5 months. After one year of follow up, 57.1% of the recurrences were diagnosed and 82.1% after 2 years of followup. The median post-recurrence survival rate was 4.7 months. After adjusting for a multivariate regression model, the variable with an independent effect for predicting recurrence is the TNM classification (HR = 8.49). CONCLUSIONS: The majority of the recurrences will be developed during the 2 years after surgery, with a very poor prognosis. The predictor variable for recurrence is the TMN classification

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Factores pronósticos en adultos hospitalizados por neumonía causada por Legionella pneumophila / Prognostic factors in adult patients hospitalized for pneumonia caused by Legionella pneumophila

Introduction: Legionellosis is a multisystem bacterial disease, which causes pneumonia with high mortality in patients with comorbidity and admitted in intensive care units (ICU). Objective: Determine predictors of mortality or ICU admission. Methods: Retrospective follow-up of patients diagnosed with Legionella pneumophila pneumonia in Complexo Hospitalario Universitario de A Coruña. Period 2000-2013 (n = 240). Analysis of multivariate logistic regression was performed. Results: Mean age was 57.2 ± 15.4 years old, 88.3% were male. Average score of comorbidity (Charlson score) was 2.3 ± 2.3. There was a clear seasonal variation. Predominant symptoms were fever (92.5%), dry cough (38.1%) and dyspnea (33.9%). Creatinine clearance was lower than 60 mL/min/1.73 m² in 29.7% and sodium < 135 mEq/l in 58.3%. Admission to ICU rate was 16.3% and 10.8% needs mechanical ventilation. Inhospital mortality rate was 4.6%, rising to 23.1% in patients admitted to ICU. Variables associated to predict ICU admission were age (OR = 0.96), liver disease (OR = 7.13), dyspnea (OR = 4.33), delirium (OR = 5.86) and high levels of lactatedehydrogenase (OR = 1.002). Variables associated with inhospital mortality were Charlson index (OR = 1.70), mechanical ventilation (OR = 31.44) and high levels of lactatedehydrogenase (OR = 1.002). Discussion: Younger patients with liver disease, dyspnea and confusion are more likely to be admitted to ICU. Comorbidity, mechanical ventilation and elevated LDH levels are associated with higher mortality rate.

Introducción: La legionelosis es una enfermedad bacteriana multisistémica, causante de neumonías con mortalidad elevada en pacientes con comorbilidad e ingresos en Unidad de Cuidados Intensivos (UCI). Objetivo: Determinar factores pronósticos de mortalidad o ingreso en UCI. Material y Métodos: Estudio de seguimiento retrospectivo de pacientes diagnosticados de neumonía por Legionella pneumophila en Complexo Hospitalario Universitario de A Coruña (España). Período 2000-2013 (n = 240), con análisis de regresión logística multivariada. Resultados: La edad media fue 57,2 ± 15,4 años, 88,3% fueron hombres. La puntuación media de comorbilidad (score Charlson) fue 2,3 ± 2,3. Existe clara estacionalidad. La clínica predominante fue fiebre (92,5%), tos seca (38,1%) y disnea (33,9%). El 29,7% presentó aclaramiento de creatinina < 60 mL/min/1,73 m² y el 58,3% sodio < 135 mEq/l. Un 16,3% ingresó en UCI, precisando ventilación mecánica invasiva el 10,8%. La mortalidad global fue 4,6% y de 23,1% en ingresados en UCI. Variables asociadas para predecir ingreso en UCI fueron menor edad (OR = 0,96), hepatopatía (OR = 7,13), disnea (OR = 4,33), síndrome confusional (OR = 5,86) y lactato deshidrogenasa elevada (OR = 1,002). Las variables asociadas a mortalidad intrahospitalaria fueron índice de Charlson (OR = 1,70), ventilación mecánica invasiva (OR = 31,44) y cifras elevadas de lactato deshidrogenasa (OR = 1,002). Discusión: Pacientes jóvenes, con hepatopatía, disnea o confusión tienen más probabilidad de ingresar en UCI. Comorbilidad, ventilación mecánica y lactato deshidrogenasa elevada se asocian a mortalidad.