Concordance between risk scales for venous thromboembolism in patients treated in emergency departments. / Concordancia entre las escalas de valoración del riesgo de tromboembolismo venoso en pacientes con patología médica en urgencias.

OBJECTIVE: To evaluate agreement between risk-assessment models for venous thromboembolism (VTE) in patients hospitalized for medical conditions and to analyze variables associated with the decision to prescribe pharmacological thromboprophylaxis in hospital emergency departments (EDs). Conclusions. METHODS: Prospective observational multicenter cohort study. We included adults attended in 15 hospital EDs who were hospitalized for medical conditions, calculating VTE risk according to the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) score, the Padua Prediction Score (PPS), and the National Institute for Health and Care Excellence (NICE) score. In addition to assessing interscore concordance, we analyzed variables associated with the prescription of thromboprophylaxis in the ED. RESULTS: A total of 1203 patients were included. The PADUA, IMPROVE, and NICE scales assigned high risk scores for 68.7%, 47.4%, and 69.5% of the patients, respectively. The κ statistic for agreement between the PADUA and NICE scores was 0.80 (95% CI, 0.76-0.84); 102 patients (8.5%) had discordant scores. The κ statistics for agreement between the IMPROVE score and the PADUA and NICE classifications were 0.47 (95% CI, 0.43-0.52) and 0.37 (95% CI, 0.33-0.42), respectively; 322 (26.8%) and 384 patients (31.9%), respectively, had discordant scores. Variables associated with starting thromboprophylaxis in the ED were a diagnosis of acute myocardial infarction or stroke (adjusted odds ratio [aOR], 4.26), immobility in the last 2 months (aOR, 2.19), chronic obstructive pulmonary disease (aOR, 1.97), ischemic heart disease (aOR, 1.51), reduced mobility of 3 days or longer (aOR, 1.14), body mass index (aOR, 1.04), age (aOR, 1.02), recent trauma or surgery (aOR, 0.40), and risk for bleeding (aOR, 0.56). CONCLUSIONS: There is disagreement among the recommended models for predicting risk for VTE in patients hospitalized for medical conditions. The basis for emergency physicians' clinical judgment regarding thromboprophylaxis extends beyond risk scales to include multiple risk factors for VTE and bleeding.

OBJETIVO: Evaluar la concordancia entre las escalas de riesgo de enfermedad tromboembólica venosa (ETV) de pacientes médicos hospitalizados y analizar las variables asociadas a la decisión de instaurar tromboprofilaxis farmacológica en los servicios de ur gencias(SUH). METODO: Se trata de un estudio de cohorte observacional prospectivo multicéntrico que incluyó pacientes adultos atendidos en 15 SUH españoles que requerían ingreso por patología médica. Se calculó la puntuación según las escalas IMPROVE, PADUA y NICE. Se evaluó la concordancia entre ellas, y las variables asociadas a la indicación de tromboprofilaxis en urgencias. RESULTADOS: Se incluyeron 1.203 pacientes. Las escalas PADUA, IMPROVE y NICE clasificaron de riesgo alto al 68,7%, 47,4% y 69,5% de los pacientes, respectivamente. PADUA y NICE mostraron un índice Kappa de 0,80 (IC 95%: 0,76-0,84) y discordancia del 8,5% (102 pacientes). IMPROVE con PADUA y NICE mostró un índice Kappa de 0,47 (IC 95%:0,43-0,52) y 0,37 (0,33-0,42), con una discordancia del 26,8% (322 pacientes) y 31,9% (384 pacientes), respectivamente. Las variables asociadas con la instauración de tromboprofilaxis fueron infarto agudo de miocardio o ictus (odss ratio ajustada ­ORa­ 4,26), inmovilidad 2 meses previos (ORa 2,19), enfermedad pulmonar obstructiva crónica (ORa 1,97), cardiopatía isquémica (ORa 1,51), movilidad reducida $ 3 días (ORa 1,14), índice masa corporal (ORa 1,04), edad (ORa 1,02), trauma o cirugía recientes (ORa 0,40) y factores de riesgo hemorrágicos (ORa 0,56). CONCLUSIONES: Existe disconcordancia entre las escalas recomendadas para valorar el riesgo de ETV en pacientes médicos hospitalizados. El juicio clínico del urgenciólogo para decidir la tromboprofilaxis se basa en la presencia de múltiples factores de riesgo de ETV y sangrado, más allá de las escalas.

Validez en la predicción de riesgo de la escala SCORE en una población mediterránea con hipertensión arterial / Predictive validity of the risk SCORE model in a Mediterranean population with arterial hypertension

Introducción y objetivos: La hipertensión arterial es el factor de riesgo más prevalente a nivel global. Se recomienda el cálculo del riesgo cardiovascular en pacientes hipertensos antes del inicio del tratamiento. Este estudio tuvo como objetivo evaluar el valor predictivo y la utilidad clínica de la escala SCORE para prevenir eventos cardiovasculares y mortalidad por todas las causas en los pacientes con hipertensión arterial. Métodos: Se incluyeron los pacientes con hipertensión arterial de la cohorte ESCARVAL-RISK. El riesgo cardiovascular se calculó mediante la escala SCORE. Todas las muertes y eventos cardiovasculares se registraron durante un periodo de 5 años de seguimiento. Se calculó la sensibilidad, la especificidad y los valores predictivos para diferentes puntos de corte, y se evaluó el efecto de diferentes factores de riesgo sobre la exactitud diagnóstica de las gráficas SCORE. Resultados: En una cohorte final de 9.834 pacientes, hubo 555 eventos cardiovasculares y 69 muertes. El valor de riesgo recomendado para iniciar tratamiento farmacológico (5%) presentó una especificidad del 92% para la muerte y del 91% para los eventos cardiovasculares, y una sensibilidad del 20% para la muerte y del 22% para los eventos cardiovasculares. Además, la escala clasificó al 80,4% de los pacientes que sufrieron un evento cardiovascular, y al 78,3% de los que murieron, como de bajo riesgo. La edad, el índice de masa corporal, la retinopatía y el tratamiento anticoagulante se asociaron con una reducción en la capacidad predictiva de la escala SCORE, mientras que ser mujer se asoció con mejor predicción de riesgo. Conclusiones: La capacidad predictiva de la escala SCORE para la enfermedad cardiovascular y la mortalidad total en los pacientes con hipertensión arterial es limitada.(AU)

Introduction and objectives: Hypertension is the most prevalent risk factor globally. Calculation of cardiovascular risk in hypertensive patients before initiation of treatment is recommended. This study aimed to assess the predictive value and clinical utility of the SCORE scale in preventing cardiovascular events and all-cause mortality in patients with hypertension. Methods: Patients with hypertension from the ESCARVAL-RISK cohort were included. Cardiovascular risk was calculated using the SCORE scale. All deaths and cardiovascular events were recorded during a 5-year follow-up period. Sensitivity, specificity and predictive values were calculated for different cut-off points and the effect of different risk factors on the diagnostic accuracy of SCORE charts were assessed. Results: In a final cohort of 9834 patients, there were 555 cardiovascular events and 69 deaths. The recommended risk value for initiating drug treatment (5%) had a specificity of 92% for death and 91% for cardiovascular events, and a sensitivity of 20% for death and 22% for cardiovascular events. In addition, the scale classified 80.4% of patients who experienced a cardiovascular event and 78.3% of those who died as low risk. Age, body mass index, retinopathy and anticoagulant therapy were associated with reduced predictive ability of the SCORE scale, while being female was associated with better risk prediction. Conclusions: The predictive ability of the SCORE scale for cardiovascular disease and total mortality in patients with hypertension is limited.(AU)

[Predictive validity of the risk SCORE model in a Mediterranean population with arterial hypertension]. / Validez en la predicción de riesgo de la escala SCORE en una población mediterránea con hipertensión arterial.

INTRODUCTION AND OBJECTIVES: Hypertension is the most prevalent risk factor globally. Calculation of cardiovascular risk in hypertensive patients before initiation of treatment is recommended. This study aimed to assess the predictive value and clinical utility of the SCORE scale in preventing cardiovascular events and all-cause mortality in patients with hypertension. METHODS: Patients with hypertension from the ESCARVAL-RISK cohort were included. Cardiovascular risk was calculated using the SCORE scale. All deaths and cardiovascular events were recorded during a 5-year follow-up period. Sensitivity, specificity and predictive values were calculated for different cut-off points and the effect of different risk factors on the diagnostic accuracy of SCORE charts were assessed. RESULTS: In a final cohort of 9834 patients, there were 555 cardiovascular events and 69 deaths. The recommended risk value for initiating drug treatment (5%) had a specificity of 92% for death and 91% for cardiovascular events, and a sensitivity of 20% for death and 22% for cardiovascular events. In addition, the scale classified 80.4% of patients who experienced a cardiovascular event and 78.3% of those who died as low risk. Age, body mass index, retinopathy and anticoagulant therapy were associated with reduced predictive ability of the SCORE scale, while being female was associated with better risk prediction. CONCLUSIONS: The predictive ability of the SCORE scale for cardiovascular disease and total mortality in patients with hypertension is limited.

[Luces y sombras de la Guía Europea esc-2021 de Prevención de la Enfermedad Cardiovascular en la Práctica Clínica.] / Lights and shadows of the 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice.

General practitioners see in their consultation a a significant number of patients at high vascular risk (VR). The European Guidelines for Cardiovascular Disease Prevention (2021) recommend a new risk classification and intervention strategies on on vascular risk factors (RF), with the aim of providing a shared decision-making recommendations between professionals and patients. In this document we present a critical analysis of these guidelines, offering possible solutions that can be implemented in Primary Care. It should be noted that there are positive aspects (lights) such as that the SCORE2 (from forty to sixty-nine years) and SCORE2-OP models (from seventy to eighty-nine years) are based on more current cohorts and measure cardiovascular risk in a more accurately manner. In addition, it is proposed to differentiate different risk thresholds according to age-groups. For sake of practicality, cardiovascular risk can be estimated using different websites with the new computer models. However, among the negative aspects (shadows), it seems to be add complexity implementing nine subgroups of subjects according to their age or level of risk, with a defined thresholds that could cause a substantial increase in the potential number of subjects susceptible to treatment without a clear evidence that supports it. In addition, two-step RF interventions could delay achievement of therapeutic goals, especially in very high-risk patients, diabetics, or patients with cardiovascular disease. Given these limitations, in this document we propose practical recommendations in order to simplify and facilitate the implementation of the guideline in primary care.

Los médicos de familia atienden un importante número de pacientes con alto riesgo vascular (RV). Las Guías Europeas de Prevención Cardiovascular (2021) proponen una nueva clasificación del riesgo y estrategias de intervención sobre los factores de riesgo (FRV), orientada a la toma de decisiones compartidas entre profesionales y pacientes. En el presente trabajo realizamos un análisis crítico de dichas guías, ofreciendo posibles soluciones prácticas para la Atención Primaria. Son destacables aspectos positivos (luces) que los modelos de RV SCORE2 (entre cuarenta y sesenta y nueve años) y SCORE2-OP (entre setenta y ochenta y nueve años) se basan en cohortes más actuales y miden con mayor exactitud y discriminación dicho riesgo. Además, se propone actuar diferenciadamente sobre el riesgo según la edad. Pragmáticamente, se presentan nuevos modelos informáticos para calcular el riesgo. Sin embargo, entre los aspectos negativos (sombras), parece colegirse una mayor dificultad de implementación al proponerse nueve subgrupos de sujetos según su edad o nivel de riesgo, con un dintel definitorio de alto RV subjetivo que podría ocasionar un incremento sustancial en el número de sujetos susceptibles de tratar sin una discriminación objetiva que lo sustente. Además, las intervenciones sobre los FRV en dos pasos podrían retrasar la consecución de objetivos terapéuticos, sobre todo en pacientes de muy alto riesgo, diabéticos o con enfermedad cardiovascular. Ante las dificultades que plantea la valoración del riesgo, proponemos unificar criterios y simplificar los mensajes claves para hacer unas guías más atractivas y que realmente ayuden a los profesionales de Atención Primaria en su práctica habitual.

The TG/HDL-c Lipid Ratio as a Cardiovascular Risk Marker in a Mexican Urban Middle-Class Population: Do We Need a Risk Score Tailored for Mexicans?

INTRODUCTION: Risk scores are essential in primary prevention to detect high-risk patients. The most common scores exclude hypertriglyceridemia and abdominal obesity in their risk assessment. We examined the triglyceride/HDL-cholesterol (TG/HDL-c) ratio as a cardiovascular (CV) risk marker in a middle-class urban Mexican population sample. AIM: Our aim was to test the concept of a scoring system reflecting Mexican population characteristics. METHODS: A total of 2602 healthy adults from the Lindavista primary prevention program were considered, evaluating gender, age, blood pressure, smoking, body mass index, waist circumference, lipid profile, and fasting glucose. According to the abnormality, a score from -3 to +3 was assigned. RESULTS: The summation of eleven variables yielded the Lindavista score (LS), which was calibrated versus the TG/HDL ratio and ACC ASCVD Risk Estimator Plus score to determine its correlation with risk categories. The TG/HDL-c ratio had a linear correlation with LS and high-risk ACC ASCVD categories. CONCLUSIONS: Compared with LS and TG/HDL-c, the ACC ASCVD system underestimates the high-risk category. The high prevalence of obesity and lipid triad in the Mexican population requires a scale that considers those traits. The TG/HDL-c ratio is a practical, easy, and economical instrument to categorize risk in Mexicans.

Luces y sombras de la Guía Europea ESC-2021 de Prevención de la Enfermedad Cardiovascular en la Práctica Clínica / Lights and shadows of the 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice

Los médicos de familia atienden un importante número de pacientes con alto riesgo vascular (RV). LasGuías Europeas de Prevención Cardio-vascular (2021) proponen una nueva clasificación del riesgo y estrategias de intervención sobre los factores de riesgo (FRV), orientada a la tomade decisiones compartidas entre profesionales y pacientes. En el presente trabajo realizamos un análisis crítico de dichas guías, ofreciendoposibles soluciones prácticas para la Atención Primaria.Son destacables aspectos positivos (luces) que los modelos de RV SCORE2 (entre cuarenta y sesenta y nueve años) y SCORE2-OP (entre setenta yochenta y nueve años) se basan en cohortes más actuales y miden con mayor exactitud y discriminación dicho riesgo. Además, se propone actuardiferenciadamente sobre el riesgo según la edad. Pragmáticamente, se presentan nuevos modelos informáticos para calcular el riesgo. Sin embargo,entre los aspectos negativos (sombras), parece colegirse una mayor dificultad de implementación al proponerse nueve subgrupos de sujetos segúnsu edad o nivel de riesgo, con un dintel definitorio de alto RV subjetivo que podría ocasionar un incremento sustancial en el número de sujetossusceptibles de tratar sin una discriminación objetiva que lo sustente. Además, las intervenciones sobre los FRV en dos pasos podrían retrasar laconsecución de objetivos terapéuticos, sobre todo en pacientes de muy alto riesgo, diabéticos o con enfermedad cardiovascular.Ante las dificultades que plantea la valoración del riesgo, proponemos unificar criterios y simplificar los mensajes claves para hacer unas guíasmás atractivas y que realmente ayuden a los profesionales de Atención Primaria en su práctica habitual.(AU)

General practitioners see in their consultation a a significant number of patients at high vascular risk (VR). The European Guidelines forCardiovascular Disease Prevention (2021) recommend a new risk classification and intervention strategies on on vascular risk factors (RF), withthe aim of providing a shared decision-making recommendations between professionals and patients. In this document we present a criticalanalysis of these guidelines, offering possible solutions that can be implemented in Primary Care.It should be noted that there are positive aspects (lights) such as that the SCORE2 (from forty to sixty-nine years) and SCORE2-OP models (fromseventy to eighty-nine years) are based on more current cohorts and measure cardiovascular risk in a more accurately manner. In addition, it isproposed to differentiate different risk thresholds according to age-groups. For sake of practicality, cardiovascular risk can be estimated usingdifferent websites with the new computer models. However, among the negative aspects (shadows), it seems to be add complexity implemen-ting nine subgroups of subjects according to their age or level of risk, with a defined thresholds that could cause a substantial increase in thepotential number of subjects susceptible to treatment without a clear evidence that supports it. In addition, two-step RF interventions coulddelay achievement of therapeutic goals, especially in very high-risk patients, diabetics, or patients with cardiovascular disease.Given these limitations, in this document we propose practical recommendations in order to simplify and facilitate the implementation of theguideline in primary care.(AU)

Clinical Validation of the Shock Index, Modified Shock Index, Delta Shock Index, and Shock Index-C for Emergency Department ST-Segment Elevation Myocardial Infarction.

Background: ST-segment elevation myocardial infarction (STEMI) is a leading cause of death worldwide. A shock index (SI), modified SI (MSI), delta-SI, and shock index-C (SIC) are known predictors of STEMI. This retrospective cohort study was designed to compare the predictive value of the SI, MSI, delta-SI, and SIC with thrombolysis in myocardial infarction (TIMI) risk scales. Method: Patients > 20 years old with STEMI who underwent percutaneous coronary intervention (PCI) were included. Receiver operating characteristic (ROC) curve analysis with the Youden index was performed to calculate the optimal cutoff values for these predictors. Results: Overall, 1552 adult STEMI cases were analyzed. The thresholds for the emergency department (ED) SI, MSI, SIC, and TIMI risk scales for in-hospital mortality were 0.75, 0.97, 21.00, and 5.5, respectively. Accordingly, ED SIC had better predictive power than the ED SI and ED MSI. The predictive power was relatively higher than TIMI risk scales, but the difference did not achieve statistical significance. After adjusting for confounding factors, the ED SI > 0.75, MSI > 0.97, SIC > 21.0, and TIMI risk scales > 5.5 were statistically and significantly associated with in-hospital mortality of STEMI. Compared with the ED SI and MSI, SIC (>21.0) had better sensitivity (67.2%, 95% CI, 58.6−75.9%), specificity (83.5%, 95% CI, 81.6−85.4%), PPV (24.8%, 95% CI, 20.2−29.6%), and NPV (96.9%, 95% CI, 96.0−97.9%) for in-hospital mortality of STEMI. Conclusions: SIC had better discrimination ability than the SI, MSI, and delta-SI. Compared with the TIMI risk scales, the ACU value of SIC was still higher. Therefore, SIC might be a convenient and rapid tool for predicting the outcome of STEMI.

Use of MeNTS, Frailty and Symptom Scales for selecting surgical patients during the SARS-CoV-2 pandemic: A retrospective study / Uso de escalas MeNTS, Fragilidad y Síntomas para la selección de pacientes quirúrgicos durante la pandemia por SARS-CoV-2: Estudio retrospectivo

Abstract Introduction: The SARS-CoV-2 pandemic has led to the cancellation of non-emergent surgeries in order to optimize the use of resources. Once the elective medical services are restored, a technical and ethical strategy becomes critical to select candidate patients for elective surgery. Objective: To describe the results from the implementation of MeNTS (Medically Necessary Time-sensitive Procedures), FI-CGA, and survey on COVID-19 symptoms Scales, as methods for the selection of patients who were candidates for elective surgery during the SARS-CoV-2 pandemic, in a third level institution in Cali, Colombia. Methods: The databases of the results on the administration of MeNTS, frailty index (FI-CGA) and COVID 19 symptoms scales in patients who were candidates for elective surgery in a third level clinic in Cali city, between March 1st and August 31st, 2020 were reviewed. Results: A total of 1,044 patients were included, of which 647 (62.0 %) were females, with a median age of52 years (interquartile range [IQR] 38-62). 98 % of the patients were asymptomatic, the overall median score for MeNTS was 48 (IQR 44-52) and the average for FI-CGA was 0.0 (standard deviation 0.1). Conclusions: MeNTS, FI-CGA and the Symptoms Survey are easily accessible scales amidst the pandemic and are helpful to select patients with intermediate and low risk of perioperative morbidity in elective surgery during the SARS-CoV-2 pandemic. Further studies are required to confirm these findings and to clarify the potential of these tools in the selection of patients that meet the high-risk criteria.

Resumen Introducción: La pandemia por SARS-CoV-2 ha ocasionado la suspensión de cirugías no urgentes con el fin de optimizar los recursos. Una vez los servicios médicos electivos son restablecidos, es fundamental disponer de una estrategia técnica y ética para la selección de los pacientes candidatos a cirugía electiva. Objetivo: Describir los resultados observados durante la implementación de las escalas MeNTS (Medically Necessary Time-sensitive Procedures), IF-VIG y Encuesta de síntomas para COVID-19, como métodos de selección de pacientes candidatos a cirugía electiva durante la pandemia por SARS-CoV-2 en una institución de nivel tres en la ciudad de Cali, Colombia. Metodología: Se revisaron las bases de datos de los resultados de la aplicación de escalas de MeNTS, índice de fragilidad (IF-VIG) y los síntomas para COVID 19, en pacientes candidatos a cirugía electiva en una clínica de tercer nivel en la ciudad de Cali, entre marzo 1 y agosto 31 del 2020. Resultados: En total 1.044 pacientes fueron incluidos, de los cuales 647 (62,0 %) fueron mujeres con una mediana de edad de 52 años (rango intercuartil [RIC] 38-62). El 98 % de los pacientes estuvieron asintomáticos, la mediana general de la puntuación total de MeNTS fue 48 (RIC 44-52) y el promedio para IF-VIG fue de 0,0 (desviación estándar 0,1). Conclusiones: MeNTS, IF-VIG y Encuesta de síntomas, son escalas fácilmente accesibles durante tiempos de pandemia y son de utilidad para seleccionar pacientes de riesgo intermedio y bajo de morbilidad perioperatoria en cirugía electiva durante la pandemia por SARS-CoV-2. Se requieren futuros estudios para confirmar estos hallazgos y para clarificar su potencial en la selección de pacientes con criterios que los definan como de riesgo alto.

The impact of frailty in aortic valve surgery.

BACKGROUND: Frailty is a geriatric syndrome that diminishes potential functional recovery after any surgical procedure. Preoperative surgical risk assessment is crucial to calibrate the risk and benefit of cardiac surgery. The aim of this study was to test usefulness of FRAIL Scale and other surgical-risk-scales and individual features of frailty in cardiac aortic valve surgery. METHODS: Prospective study. From May-2014 to February-2016, we collected 200 patients who underwent aortic valve replacement, either surgically or transcatheter. At 1-year follow-up, quality of life measurements were recorded using the EQ-5D (EuroQol). Univariate and multivariate analyses correlated preoperative condition, features of frailty and predicted risk scores with mortality, morbidity and quality of life at 1 year of follow-up. RESULTS: Mean age 78.2y, 56%male. Mean-preoperative-scores: FRAIL scale 1.5(SD 1.02), STS 2.9(SD 1.13), BI 93.8(SD 7.3), ESlog I 12.8(SD 8.5) and GS 7.3 s (SD 1.9). Morbidity at discharge, 6 m and 1 year was 51, 14 and 28%. Mortality 4%. Survival at 6 m/ 1-y was 97% / 88%. Complication-rate was higher in TAVI group due to-vascular complications. Renal dysfunction, anemia, social dependence and GS slower than 7 s were associated with morbidity. On multivariate analysis adjusted STS, BI and GS speed were statistically significant. Quality of life at 1-year follow-up adjusted for age and prosthesis type showed a significant association with STS and FRAIL scale scores. CONCLUSIONS: Frailty increases surgical risk and is associated with higher morbidity. Preoperative GS slower 7 s, and STS and FRAIL scale scores seem to be reliable predictors of quality of life at 1-year follow-up.

Evaluation of risk factors for adverse outcome in extracorporeal membrane oxygenation-supported elderly postcardiotomy patients.

BACKGROUND: Recently extracorporeal membrane oxygenation is becoming the commonly used mechanical assist device for the treatment of severe cardiogenic shock in postcardiotomy patients. Evaluation of risk factors of negative outcome would be beneficial in decision-making in the elderly patient population. METHODS: This was a retrospective single-centre analysis of elderly patients who underwent extracorporeal membrane oxygenation treatment for refractory cardiogenic shock in a tertiary care centre. Demographic data, comorbidities and perioperative parameters were collected to evaluate their impact on the outcome of extracorporeal membrane oxygenation treatment in this patient group. Logistic regression analysis of the variables was performed to identify factors predicting an adverse outcome. RESULTS: Forty consecutive elderly patients underwent extracorporeal membrane oxygenation treatment during the study period. The mean age was 76.7 ± 3.8 years, 27 (68%) were male. The mean Survival after Veno-Arterial extracorporeal membrane oxygenation score before initiating extracorporeal membrane oxygenation support was - 11 ± 6. Intra-aortic counterpulsation was used as the first-line mechanical support in 31 (77%) patients. The mean duration of extracorporeal membrane oxygenation support was 172 ± 128 hours. Twenty-four patients (56%) were successfully weaned from extracorporeal membrane oxygenation, and 8 (20%) survived to hospital discharge. Lactate level before extracorporeal membrane oxygenation initiation was the only predictor of unfavourable outcome in multivariate analysis (p < 0.05). CONCLUSION: High lactate level before initiation of extracorporeal membrane oxygenation was the most important prognostic values of an unfavourable outcome.

Agreement between Type 2 Diabetes Risk Scales in a Caucasian Population: A Systematic Review and Report.

Early detection of people with undiagnosed type 2 diabetes (T2D) is an important public health concern. Several predictive equations for T2D have been proposed but most of them have not been externally validated and their performance could be compromised when clinical data is used. Clinical practice guidelines increasingly incorporate T2D risk prediction models as they support clinical decision making. The aims of this study were to systematically review prediction scores for T2D and to analyze the agreement between these risk scores in a large cross-sectional study of white western European workers. A systematic review of the PubMed, CINAHL, and EMBASE databases and a cross-sectional study in 59,042 Spanish workers was performed. Agreement between scores classifying participants as high risk was evaluated using the kappa statistic. The systematic review of 26 predictive models highlights a great heterogeneity in the risk predictors; there is a poor level of reporting, and most of them have not been externally validated. Regarding the agreement between risk scores, the DETECT-2 risk score scale classified 14.1% of subjects as high-risk, FINDRISC score 20.8%, Cambridge score 19.8%, the AUSDRISK score 26.4%, the EGAD study 30.3%, the Hisayama study 30.9%, the ARIC score 6.3%, and the ITD score 3.1%. The lowest agreement was observed between the ITD and the NUDS study derived score (κ = 0.067). Differences in diabetes incidence, prevalence, and weight of risk factors seem to account for the agreement differences between scores. A better agreement between the multi-ethnic derivate score (DETECT-2) and European derivate scores was observed. Risk models should be designed using more easily identifiable and reproducible health data in clinical practice.

Risk assessment scales to predict risk of hospital treated repeat self-harm: A cost-effectiveness modelling analysis.

BACKGROUND: Risk scales are used widely for assessing individuals presenting to Emergency Departments (EDs) following self-harm. There is growing evidence that risk scales have limited clinical utility in identifying episodes at highest risk of repeat self-harm. However, their cost-effectiveness in terms of treatment allocation and subsequent repeat self-harm is unknown. We aimed to examine the cost-effectiveness of five risk scales (SAD PERSONS Scale, Modified SAD PERSONS Scale, ReACT Self-Harm Rule, Manchester Self-Harm Rule, Barratt Impulsivity Scale) and single item clinician and patient ratings of risk. METHOD: Quality-Adjusted Life Years were estimated for each episode. The five risk scales and the patient rating were compared to the clinician rating. Incremental cost-effectiveness ratios (ICERs) were estimated for each scale, using a range of ICER thresholds. Sensitivity analysis explored different model assumptions. RESULTS: The formal scales were less cost-effective than the clinician and patient ratings across a range of ICER thresholds (£0-£30,000). The five scales were also less cost-effective than the clinician rating in most alternative scenario analyses. However, the clinician rating would be likely to result in unnecessary treatment costs for over half of patients identified as high risk. LIMITATIONS: Our primary model depended on the assumption that high-intensity care reduced patients' risk of further self-harm. CONCLUSION: The use of formal assessment tools for managing self-harm presentations to EDs did not appear to be cost-effective. While the judgement of a mental health clinician was found to be slightly more cost-effective, it still resulted in incorrect allocation of costs and missed treatment opportunities.

Surgery for pancreatic ductal adenocarcinoma.

Surgical resection is the only potentially curative option in the treatment of pancreatic ductal adenocarcinoma. Preoperative radiological imaging allows to rule out the presence of metastases. Three resectability categories are established based on the radiological findings depending on the degree of contact between the tumor and the blood vessels. Histological confirmation of malignancy is only required in cases of borderline or non-resectable tumors, prior to neoadjuvant treatment initiation. Diagnostic laparoscopy is recommended in the presence of large tumors of the body or tail and in borderline tumors to explore the possibility of resection and to apply treatment with curative intent, as well as in those cases with high level of biomarkers to rule out peritoneal involvement. Prior to surgery preoperative nutritional measures as well as endoscopic biliary drainage can be applied to optimize patient's conditions. Cephalic pancreaticoduodenectomy is the recommended surgical technique in tumors located in the head of the pancreas. The benefits from pyloric preservation, type or reconstruction (one vs. two loops), type of anastomosis (pancreaticojejunostomy vs. pancreaticogastrostomy), intraoperative biopsy of the pancreatic resection margin or the use of intraperitoneal drainages are inconclusive. Total pancreatectomy and/or portal resection should only be performed in particular cases; however, arterial resections have shown no benefits. Radical antegrade modular pancreaticosplenectomy, that can be performed laparoscopically, is the technique used for those tumors located in the pancreatic body-tail.