Clinical prediction rules in acute appendicitis: which combination of variables is more effective at predicting?

BACKGROUND: Clinical prediction rules have been designed to reduce variability and improve the diagnostic process. However, there are no unanimous criteria regarding which of them is the most efficient for the diagnosis of acute appendicitis. AIM: The primary aim of this study was to assess the diagnostic efficacy of the most commonly used clinical prediction rules. The second aim was to identify the combination of the smallest number of clinical and analytical variables that would allow a cost-effective diagnostic approach. METHODS: A retrospective observational study was conducted of 458 patients who were evaluated for right iliac fossa pain between January 2010 and December 2016. The scores tested were Alvarado, AIR, RIPASA, and AAS. Univariate and multiple regressions were used for validation. RESULTS: Alvarado one was the most efficient to establish a positive diagnosis of acute appendicitis. However, the most simplified and predictive combination variables included anorexia, white blood cell count > 8275 leukocytes/mL, neutrophilia (> 75%), abdominal pain < 48 h, migrating pain, and temperature out the range of 37-39ºC. CONCLUSIONS: A new and effective CPR (HMC score) for predicting appendicitis in patients presenting with the right iliac fossa pain has been established.

INTRODUCCIÓN: Las escalas de predicción diagnóstica (EPD) se han diseñado con el objetivo de reducir la variabilidad y mejorar el proceso de diagnóstico. Sin embargo, no existen criterios unánimes sobre cuál de ellas es la más el más eficiente para el diagnóstico de apendicitis aguda. OBJETIVO: El objetivo principal de este estudio fue evaluar la eficacia diagnóstica de las escalas de predicción diagnóstica más utilizadas. El segundo objetivo fue identificar la combinación del menor número de variables clínicas y analíticas que permitieran un enfoque diagnóstico más eficiente. MÉTODOS: Se realizó un estudio observacional retrospectivo de 458 pacientes que fueron evaluados por dolor en la fosa ilíaca derecha entre enero de 2010 y diciembre de 2016. Las escalas evaluadas fueron las de Alvarado, AIR, RIPASA y AAS. Se utilizaron la regresion univariada y la múltiple para la validación de los resultados. RESULTADOS: la escala de Alvarado fue la más eficiente para establecer un diagnóstico de apendicitis aguda. No obstante, la combinación de las siguientes variables: anorexia, recuento de leucocitos > 8275 leucocitos/mL, neutrofilia (> 75%), dolor abdominal < 48 horas, dolor migratorio y temperatura fuera del rango de 37-39ºC, demostró ser la más eficiente para establecer un diagnóstico positivo de apendicitis aguda. CONCLUSIONES: Se ha desarrollada una nueva EPD (escala HMDC) para determinar la presencia de apendicitis en pacientes evaluados por dolor en la fosa ilíaca derecha.

Shared Features of Endothelial Dysfunction between Sepsis and Its Preceding Risk Factors (Aging and Chronic Disease).

Acute vascular endothelial dysfunction is a central event in the pathogenesis of sepsis, increasing vascular permeability, promoting activation of the coagulation cascade, tissue edema and compromising perfusion of vital organs. Aging and chronic diseases (hypertension, dyslipidaemia, diabetes mellitus, chronic kidney disease, cardiovascular disease, cerebrovascular disease, chronic pulmonary disease, liver disease, or cancer) are recognized risk factors for sepsis. In this article we review the features of endothelial dysfunction shared by sepsis, aging and the chronic conditions preceding this disease. Clinical studies and review articles on endothelial dysfunction in sepsis, aging and chronic diseases available in PubMed were considered. The main features of endothelial dysfunction shared by sepsis, aging and chronic diseases were: (1) increased oxidative stress and systemic inflammation, (2) glycocalyx degradation and shedding, (3) disassembly of intercellular junctions, endothelial cell death, blood-tissue barrier disruption, (4) enhanced leukocyte adhesion and extravasation, (5) induction of a pro-coagulant and anti-fibrinolytic state. In addition, chronic diseases impair the mechanisms of endothelial reparation. In conclusion, sepsis, aging and chronic diseases induce similar features of endothelial dysfunction. The potential contribution of pre-existent endothelial dysfunction to sepsis pathogenesis deserves to be further investigated.

Sugerencias sobre el análisis molecular microbiológico post mortem / Suggestions on post mortem molecular microbiology analysis

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IgM levels in plasma predict outcome in severe pandemic influenza.

BACKGROUND: Little is known on the participation of immunoglobulin isotypes and subclasses in the pathogenesis of the severe disease caused by the pandemic influenza virus (influenza A(H1N1)pdm09). OBJECTIVES: (1) To evaluate the association between plasma levels of IgG1, IgG2, IgG3, IgG4, IgA, IgM, IgE and outcome in patients with severe pandemic influenza. (2) To evaluate the association between immunoglobulin and cytokine levels in these patients. STUDY DESIGN: 40 critically ill patients with community acquired pneumonia and influenza A(H1N1)pdm09 infection were recruited from November 2010 to February 2011. Plasma samples were collected during the first 24h following admission to the ICU. Immunoglobulins and 17 major cytokines were profiled in plasma. RESULTS: 15 patients died (37.5%). When the association between clinical variables and prognosis was assessed, prior immunosuppression, APACHE II score, levels of IgG2 and levels of IgM were associated with outcome in a univariate Cox regression analysis. Kaplan Meier analysis showed that patients with levels of IgG2 and IgM < 59 and<58 mg/dl respectively died earlier. Multivariate Cox regression analysis showed that APACHE II score and levels of IgM were the best predictors of outcome, being levels of IgM a protective factor against mortality. IgM was the immunoglobulin showing the largest number of negative correlations with cytokine levels. CONCLUSIONS: Our results support a central role of IgM in preventing uncontrolled inflammatory response and mortality in severe pandemic influenza. Early assessment of IgM could contribute to guide clinical decisions in these patients.