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.

Hallux valgus in a random population in Spain and its impact on quality of life and functionality.

The aim of this study was to determine the prevalence of Hallux valgus (HV) and the association between the presence thereof and quality of life, dependence for basic and instrumental activities of daily living and foot function. Prevalence study was carried out in a random population sample (n = 1837) (α = 0.05; Precision = ±2.2%). Informed consent and ethical review board were obtained (code 2008/264). We studied anthropometric variables, Charlson Comorbidity Index, function and state of foot [Foot Function index (FFI), Foot Health Status Questionnaire (FHSQ)], quality of life (SF-36), and dependence for activities of daily living (Barthel and Lawton index). Degree of HV was determined using Manchester scale. Descriptive and multivariate logistic regression analyses were performed. Hence, the prevalence of HV is 39%. Patients with HV are significantly older (64.6 ± 11.7 vs 60.1 ± 12.6 years old). HV prevalence is greater in females (48.1 vs. 28.3%), subjects with flat foot (48.1 vs. 36.1%) or hammer toes (48.2 vs. 30.9%). Moreover, with regard to the presence or not of HV, statistically significant differences were neither noted in the SF-36 questionnaire nor in the Barthel and Lawton Index. For FHSQ and FFI questionnaires, significant differences were observed between patients who presented HV and those who did not. HV is associated with age, gender, flat foot and hammer toes. The SF-36 and Barthel and Lawton questionnaires remained unaltered by the presence of HV. The presence of Hallux valgus was associated with reduced quality of life and increases foot pain, disability and functional limitation.

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.

Incidence of cardiovascular events and associated risk factors in kidney transplant patients: a competing risks survival analysis.

BACKGROUND: The high prevalence of cardiovascular risk factors among the renal transplant population accounts for increased mortality. The aim of this study is to determine the incidence of cardiovascular events and factors associated with cardiovascular events in these patients. METHODS: An observational ambispective follow-up study of renal transplant recipients (n = 2029) in the health district of A Coruña (Spain) during the period 1981-2011 was completed. Competing risk survival analysis methods were applied to estimate the cumulative incidence of developing cardiovascular events over time and to identify which characteristics were associated with the risk of these events. Post-transplant cardiovascular events are defined as the presence of myocardial infarction, invasive coronary artery therapy, cerebral vascular events, new-onset angina, congestive heart failure, rhythm disturbances, peripheral vascular disease and cardiovascular disease and death. The cause of death was identified through the medical history and death certificate using ICD9 (390-459, except: 427.5, 435, 446, 459.0). RESULTS: The mean age of patients at the time of transplantation was 47.0 ± 14.2 years; 62% were male. 16.5% had suffered some cardiovascular disease prior to transplantation and 9.7% had suffered a cardiovascular event. The mean follow-up period for the patients with cardiovascular event was 3.5 ± 4.3 years. Applying competing risk methodology, it was observed that the accumulated incidence of the event was 5.0% one year after transplantation, 8.1% after five years, and 11.9% after ten years. After applying multivariate models, the variables with an independent effect for predicting cardiovascular events are: male sex, age of recipient, previous cardiovascular disorders, pre-transplant smoking and post-transplant diabetes. CONCLUSIONS: This study makes it possible to determine in kidney transplant patients, taking into account competitive events, the incidence of post-transplant cardiovascular events and the risk factors of these events. Modifiable risk factors are identified, owing to which, changes in said factors would have a bearing of the incidence of events.

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 reverse evidence of rotavirus vaccines impact.

In 2010, and due to a quality problem identified in the vaccine manufacture, the rotavirus (RV) vaccination was withheld in Spain during 5 months. Our study aimed to evaluate the impact that this sudden cease had on rotavirus acute gastroenteritis (RAGE) hospitalizations. An increase in RAGE hospitalization was observed in parallel to the drop in vaccine coverage. Here, we report the first reverse evidence of rotavirus vaccine impact.

Acute gastroenteritis hospitalizations among children aged < 5 years before and after introduction of rotavirus vaccines: a hospital-based surveillance study in Galicia, Spain.

Rotavirus vaccines were licensed in Spain between late 2006 and early 2007. Rotavirus vaccination was recommended but not reimbursed by the Spanish National Health System. Significant coverage rates have been reached in Galicia, with an average of 47% since the period July 2007-June 2008. We aim to explore eventual variations in the incidence of hospitalizations for acute gastroenteritis (AGE) among children < 5 y of age before and after vaccine introduction. The annual and monthly hospitalization rates for rotavirus-related AGE and all cause AGE, before and after rotavirus vaccine introduction, were calculated by using the official surveillance system for hospital data. The annual hospitalization rates for rotavirus-related AGE in children < 5 y of age decreased by 14.8% for the period July 2008 to June 2009 and by 44.5% for the period July 2009 to June 2010 as compared with the median rate of the pre-vaccination period (July 2003 to June 2007). The corresponding decreases for all cause AGE were 29.9% and 49.0%, respectively. In children < 12 mo of age a more marked decrease was observed. Compared with pre-vaccination years, a decrease in rotavirus-related and all cause AGE hospitalization rates was observed, with a greater decline in the July 2009 to June 2010 period.

Cancer incidence in kidney transplant recipients: a study protocol.

BACKGROUND: Different publications show an increased incidence of neoplasms in renal transplant patients. The objective of this study is to determine the incidence of cancer in the recipients of renal transplants performed in the A Coruña Hospital (Spain) during the period 1981-2007. METHODS/DESIGN: During the study period 1967 kidney transplants were performed, corresponding to 1710 patients. Patients with neoplasms prior to the transplant will be excluded (n = 38). A follow-up study was carried out in order to estimate cancer incidence after transplantation.For each patient, information included donor and recipient characteristics, patients and graft survival and cancer incidence after transplantation. Incident cancer is considered as new cases of cancer after the transplant with anatomopathological confirmation. Their location will be classified according to the ICD-9.The analysis will be calculated using the indirect standardisation method. Age-adjusted cancer incidence rates in the Spanish general population will be obtained from the Carlos III Health Institute, the National Epidemiology Centre of the Ministry of Science and Technology. Crude first, second and third-year post-transplantation cancer incidence rates will be calculated for male and female recipients. The number of cases of cancer at each site will be calculated from data in the clinical records. The expected number of cancers will be calculated from data supplied by the Carlos III Health Institute. For each tumour location we will estimate the standardized incidence ratios (SIRs), using sex-specific cancer incidence rates, by dividing the incidence rate for the transplant patients by the rate of the general population. The 95% confidence intervals of the SIRs and their associated p-values will be calculated by assuming that the observed cancers follow a Poisson distribution. Stratified analysis will be performed to examine the variation in the SIRs with sex and length of follow-up.Competing risk survival analysis methods will be applied to estimate the cumulative incidence of cancer and to identify variables associated to its occurrence. DISCUSSION: Information about cancer incidence in kidney transplant patients could be useful to adapt the guidelines on post-kidney transplant follow-up on tumour screening, and evaluate the impact of intervention measures for the prevention of cancer in these patients.