Invasive Mechanical Ventilation and Risk of Hospital-Acquired Venous Thromboembolism.

BACKGROUND: This study sought to estimate the overall cumulative incidence and odds of Hospital-acquired venous thromboembolism (VTE) among critically ill children with and without exposure to invasive ventilation. In doing so, we also aimed to describe the temporal relationship between invasive ventilation and hospital-acquired VTE development. METHODS: We performed a retrospective cohort study using Virtual Pediatric Systems (VPS) data from 142 North American pediatric ICUs among children < 18 y of age from January 1, 2016-December 31, 2022. After exclusion criteria were applied, cohorts were identified by presence of invasive ventilation exposure. The primary outcome was cumulative incidence of hospital-acquired VTE, defined as limb/neck deep venous thrombosis or pulmonary embolism. Multivariate logistic regression was used to determine whether invasive ventilation was an independent risk factor for hospital-acquired VTE development. RESULTS: Of 691,118 children studied, 86,922 (12.4%) underwent invasive ventilation. The cumulative incidence of hospital-acquired VTE for those who received invasive ventilation was 1.9% and 0.12% for those who did not (P < .001). The median time to hospital-acquired VTE after endotracheal intubation was 6 (interquartile range 3-14) d. In multivariate models, invasive ventilation exposure and duration were each independently associated with development of hospital-acquired VTE (adjusted odds ratio 1.64 [95% CI 1.42-1.86], P < .001; and adjusted odds ratio 1.03 [95% CI 1.02-1.03], P < .001, respectively). CONCLUSIONS: In this multi-center retrospective review from the VPS registry, invasive ventilation exposure and duration were independent risk factors for hospital-acquired VTE among critically ill children. Children undergoing invasive ventilation represent an important target population for risk-stratified thromboprophylaxis trials.

Relationship between pediatric intensive care unit length of stay and 24-h unplanned readmission rate.

OBJECTIVE: To evaluate the relationship between pediatric intensive care unit (PICU) severity-adjusted length of stay (LOS) and 24-h unplanned readmission rate. DATA SOURCE: Data were obtained from a 10-year cohort from 2009 to 2018 from the Virtual Pediatric Systems (VPS, LLC) database. STUDY DESIGN: In this retrospective study, standardized LOS ratio was computed for each PICU as the ratio of the sum of actual LOS divided by the predicted LOS for each PICU using VPS predictive LOS model. Correlation between standardized LOS ratios and 24-h unplanned readmission rates were computed using Pearson's correlation coefficient. PRINCIPAL FINDINGS: There was practically no relationship between standardized LOS ratio and 24-h readmission rate (R2  = 0.05). DATA COLLECTION/EXTRACTION METHODS: Not Applicable. CONCLUSIONS: Severity-adjusted LOS has no relationship with 24-h unplanned readmission rate. These findings suggest that the relationship between PICU severity-adjusted LOS and 24-h unplanned readmission rate should not be used as a balancing quality measure.

Insights into equine piroplasmosis in Venezuelan sport horses: Molecular diagnosis, clinical, and cardiovascular findings.

Equine piroplasmosis (EP) is a tick-borne infectious disease highly prevalent in tropical and subtropical regions, such as Venezuela. EP affects wild and domestic equids leading to several clinical presentations, from asymptomatic to severely affected animals. In this study, thirty-three (33) sport horses under regular training activities and from endemic regions of north-central Venezuela were submitted to an observational survey, case-control, to describe the presence of clinical signs and natural EP infections. A conventional PCR assay targeting the SSU rRNA gene revealed EP etiologic agents in 13 out of 33 sampled horses (~ 39.4% infections). Nine (9) of these EP-positive samples were confirmed as infected with Babesia caballi (6/9 = 66.7%) or Theileria equi (3/9 = 33.3%) by DNA sequencing and BLASTN analyses. A phylogeny of SSU rRNA gene sequences revealed that these new B. caballi and T. equi sequences clustered within the worldwide distributed phylogenetic genotype A, respectively. No acute EP cases were observed in this study; however, six (6) PCR-positive animals displayed mild clinical signs compatible with EP, including a mild leukocytosis (P < 0.05). The heart rate variability frequency domain analysis in four (4) of these EP-positive infected animals revealed a significant (P < 0.05) higher low-frequency/high-frequency ratio suggesting a sympathovagal imbalance in these chronically infected animals. Other clinical and cardiovascular parameters were similar between the different groups. Sport horses are routinely submitted to intense training programs and sport-related activities that could lead to loss of the host-parasite equilibrium that characterizes enzootic regions, increasing the likelihood of infection reactivation and the risk of transmission. Heart rate variability analysis contributes to evaluate the sympathovagal balance and detecting homeostasis disturbances in sport horses. Molecular diagnostic tests for EP based on the detection of parasite DNA in equine blood samples should be included in the health programs of sport horses in endemic areas.

[Microscopic excision of a colloyd cyst of the third ventricle assisted by endoscopy. Case report and literature analysis.] / Exéresis microquirúrgica de quiste coloide del tercer ventrículo asistido por endoscopía. Presentación de un caso y revisión bibliográfica.

Introduction: Colloid cysts are histologically benign lesions, probably derived from the endoderm, which represent 0.3-2% of brain tumors. They are usually attached to the roof of the third ventricle in direct relation to the foramen of Monro, which can cause a blockage to the circulation of cerebrospinal fluid, determining hydrocephalus and in some cases sudden death. Other more common symptoms are headache, nausea and vomiting, blurred vision, gait ataxia, and cognitive impairment. Treatment options include microsurgery, endoscopy, stereotaxic casting, or cerebrospinal fluid shunts for the treatment of hydrocephalus. The objective of surgery is the total excision of the lesion. It should be noted that the microsurgical technique allows total excision more frequently, but at the cost of greater manipulation and tissue trauma; on the contrary, endoscopic being minimally invasive, allows better tissue preservation, although the rates of complete tumor excision are usually lower due to the difficulties in dissecting the lesions densely adhered to the roof of the third ventricle. Method: We present a clinical case of a patient with a third ventricle tumor compatible with a colloid cyst, with progressive hydrocephalus, operated with microsurgical technique and endoscopic assistance. Result: Total excision of the colloid cyst with improvement of the symptoms. Antegrade memory disorder that resolved completely after 3 months. Conclusion: The endoscopy-assisted microsurgical technique is safe for the management of this pathology and provides intraoperative benefits.

Introducción: Los quistes coloides son lesiones histológicamente benignas, probablemente derivadas del endodermo, que representan el 0,3-2% de los tumores cerebrales. Habitualmente se encuentran adheridas al techo del tercer ventrículo en relación directa con el foramen de Monro, lo que puede provocar un bloqueo a la circulación del líquido cefalorraquídeo determinando hidrocefalia y en algunos casos muerte súbita. Otros síntomas más habituales son cefalea, náuseas y vómitos, visión borrosa, ataxia de la marcha y deterioro cognitivo. Las opciones terapéuticas incluyen la microcirugía, endoscopia, vaciamiento estereotáxico o derivaciones de líquido cefalorraquídeo para el tratamiento de la hidrocefalia. El objetivo de la cirugía es la exéresis total de la lesión. Se destaca que la técnica microquirúrgica permite exéresis totales con más frecuencia, pero a costa de mayor manipulación y traumatismo tisular; por el contrario la endoscópica al ser mínimamente invasiva permite mejor preservación tisular, aunque los índices de exéresis completa del tumor suelen ser menores debido a las dificultades para disecar a las lesiones densamente adheridas al techo del tercer ventrículo. Método: Se presenta un caso clínico de un paciente con un tumor del tercer ventrículo compatible con quiste coloide, con hidrocefalia evolutiva, operado con técnica microquirúrgica y asistencia endoscópica. Resultado: Exéresis total del quiste coloide con mejoría de la sintomatología. Trastorno mnésico anterógrado que resolvió a los 3 meses completamente. Conclusión: La técnica microquirúrgica asistida por endoscopia es segura para el manejo de esta patología y aporta beneficios intraoperatorios.

Outcomes of Children With Firearm Injuries Admitted to the PICU in the United States.

OBJECTIVES: Firearm-related injury is the second leading cause of injury and death for children 1-18 years old in United States. The objective of our study was to analyze the outcomes of children admitted to the PICU with firearm injuries. DESIGN: Retrospective study. SETTING: PICUs in United States contributing data to Virtual Pediatric Systems, LLC, from January 2009 to December 2017. PATIENTS: Children age 1 month to 18 years old admitted to the PICU with firearm injury, identified by external cause of injury E-codes and International Classification of Diseases, 9th Edition, and International Classification of Diseases, 10th Edition, codes were identified. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 1,447 cases identified of which 175 (12%) died in the PICU. Unintentional firearm injury (67.7%) and assault with a firearm injury (20%) comprised 90% of the cases. Males comprised 78% of the cohort (1,122) and race distribution included 45% Black (646), 27% White (390), and 12% Hispanic (178). Among the children who died in the PICU, 55% were 13-18 years old. Children attempting suicide with a firearm were more likely to die in the PICU as compared to the other causes of firearm injury. Based on their Pediatric Overall Performance Category and Pediatric Cerebral Performance Category scores at discharge, there is high morbidity in children with firearm injuries. CONCLUSIONS: Mortality rate of children with firearm injury admitted to the PICU is high. Children admitted to the PICU with suicide attempt with a firearm carried the highest mortality. Further studies may help further define the epidemiology of firearm injuries in children and plan interventions to minimize these unnecessary deaths.

Declining Procedures in Pediatric Critical Care Medicine Using a National Database.

OBJECTIVES: To investigate the change in rate of invasive procedures (endotracheal intubation, central venous catheters, arterial catheters, and peripheral inserted central venous catheters) performed in PICUs per admission over time. Secondarily, to investigate the change in type of respiratory support over time. DESIGN: Retrospective study of prospectively collected data using the Virtual Pediatric Systems (VPS; LLC, Los Angeles, CA) database. SETTING: North American PICUs. PATIENTS: Patients admitted from January 2009 to December 2017. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 902,624 admissions from 161 PICUs included in the analysis. Since 2009, there has been a decrease in rate of endotracheal intubations, central venous catheters placed, and arterial catheters placed and an increase in the rate of peripheral inserted central venous catheter insertion per admission over time after controlling for severity of illness and unit level effects. As compared to 2009, the incident rate ratio for 2017 for endotracheal intubation was 0.90 (95% CI, 0.83-0.98; p = 0.017), for central venous line placement 0.69 (0.63-0.74; p < 0.001), for arterial catheter insertion 0.85 (0.79-0.92; p < 0.001), and for peripheral inserted central venous catheter placement 1.14 (1.03-1.26; p = 0.013). Over this time period, in a subgroup with available data, there was a decrease in the rate of invasive mechanical ventilation and an increase in the rate of noninvasive respiratory support (bilevel positive airway pressure/continuous positive airway pressure and high-flow nasal oxygen) per admission. CONCLUSIONS: Over 9 years across multiple North American PICUs, the rate of endotracheal intubations, central catheter, and arterial catheter insertions per admission has decreased. The use of invasive mechanical ventilation has decreased with an increase in noninvasive respiratory support. These data support efforts to improve exposure to invasive procedures in training and structured systems to evaluate continued competency.

Incidencia de disfagia persistente, en pacientes postoperados de fundoplicatura laparoscópica de Nissen / Incidence of persistent dysphagia, in postoperative patients of Nissen laparoscopic fundoplication

INTRODUCCIÓN. La fundoplicatura laparoscópica de Nissen es la técnica quirúrgica de elección en el tratamiento de la enfermedad por reflujo gastroesofágico, en la que la disfagia persistente postoperatoria como secuela, está presente con incidencia del 1 al 36% a nivel mundial. OBJETIVO. Determinar la incidencia de disfagia persistente, en pacientes postoperados de fundoplicatura laparoscópica de Nissen. MATERIALES Y MÉTODOS. Estudio observacional, descriptivo; con una población y muestra conocida de 15 Historias Clínicas de pacientes operados de fundoplicatura laparoscópica de Nissen en el Servicio de Cirugía General del Hospital General Dr. Fernando Quiroz Gutiérrez, Ciudad de México, periodo enero 2014 a mayo 2016. Criterios de inclusión: mayores de 18 años de ambos sexos, pos fundoplicatura laparoscópica de Nissen. Los datos se obtuvieron de las Historias Clínicas, y se aplicó un cuestionario vía telefónica. Para el análisis de datos se utilizó el programa Microsoft Excel 2013. RESULTADOS. La incidencia de disfagia persistente fue de 46,6% (7; 15), siendo frecuente en los hombres con un 60% (9; 15), frente a 40% (6; 15) en mujeres, con una incidencia por sexo de 66,6% (4;6) en mujeres y 33,3% (3; 9) en hombres. DISCUSIÓN. La detección de disfagia persistente aún requiere validación y tropicalización del test que evite sesgos al momento de su aplicación por parte de personal calificado. CONCLUSIÓN. Se determinó que la incidencia de disfagia persistente, en pacientes postoperados de fundoplicatura laparoscópica de Nissen a los 3 y 6 meses fue del 46%.

INTRODUCTION. Nissen laparoscopic fundoplication is the surgical technique of choice in the treatment of gastroesophageal reflux disease, in which persistent postoperative dysphagia as a sequel is present with an incidence of 1 to 36% worldwide. OBJECTIVE. To determine the incidence of persistent dysphagia in postoperative patients with Nissen laparoscopic fundoplication. MATERIALS AND METHODS. Observational, descriptive study; with a population and known sample of 15 Clinical Histories of patients operated on for Nissen laparoscopic fundoplication in the General Surgery Service of the General Hospital Dr. Fernando Quiroz Gutiérrez, Mexico City, period january 2014 to may 2016. Inclusion criteria: older than 18 years of both sexes, after Nissen laparoscopic fundoplication. The data were obtained from the Medical Records, and a questionnaire was applied via telephone. For data analysis, the Microsoft Excel 2013 program was used. RESULTS. The incidence of persistent dysphagia was 46,6% (7; 15), being frequent in men with 60% (9; 15), compared to 40% (6; 15) in women, with an incidence by sex of 66,6% (4; 6) in women and 33,3% (3; 9) in men. DISCUSSION. The detection of persistent dysphagia still requires validation and tropicalization of the test to avoid bias at the time of its application by qualified personnel. CONCLUSION. The incidence of persistent dysphagia in postoperative patients with Nissen laparoscopic fundoplication at 3 and 6 months was determined to be 46%.

Performance of Pediatric Mortality Prediction Scores for PICU Mortality and 90-Day Mortality.

OBJECTIVES: The use of mortality prediction scores in clinical trials in the PICU is essential for comparing patient groups. Because of the decline in PICU mortality over the last decades, leading to a shift toward later deaths, recent trials use 90-day mortality as primary outcome for estimating mortality and survival more accurately. This study assessed and compared the performance of two frequently used PICU mortality prediction scores for prediction of PICU and 90-day mortality. DESIGN: This secondary analysis of the randomized controlled Early versus Late Parenteral Nutrition in the Pediatric Intensive Care Unit trial compared the discrimination (area under the receiver operating characteristic curve) and calibration of the Pediatric Index of Mortality 3 and the Pediatric Risk of Mortality III scores for prediction of PICU and 90-day mortality. SETTING: Three participating PICUs within academic hospitals in Belgium, the Netherlands, and Canada. PATIENTS: One-thousand four-hundred twenty-eight critically ill patients 0-17 years old. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Although Pediatric Index of Mortality 3 only includes information available at the time of PICU admission, thus before any intervention in the PICU, it showed good discrimination (area under the receiver operating characteristic curve, 0.894; 95% CI, 0.892-0.896) and good calibration (no deviation from the diagonal, p = 0.58) for PICU mortality. Pediatric Risk of Mortality III, which involves the worst values for the evaluated variables during the first 24 hours of PICU stay, was statistically more discriminant (area under the receiver operating characteristic curve, 0.920; 95% CI, 0.918-0.921; p = 0.04) but poor in calibration (significant deviation from the diagonal; p = 0.04). Pediatric Index of Mortality 3 and Pediatric Risk of Mortality III discriminated equally well between 90-day mortality and survival (area under the receiver operating characteristic curve, 0.867; 95% CI, 0.866-0.869 and area under the receiver operating characteristic curve, 0.882; 95% CI, 0.880-0.884, respectively, p = 0.77), but Pediatric Risk of Mortality III was not well calibrated (p = 0.04), unlike Pediatric Index of Mortality 3 (p = 0.34). CONCLUSIONS: Pediatric Index of Mortality 3 performed better in calibration for predicting PICU and 90-day mortality than Pediatric Risk of Mortality III and is not influenced by intervention or PICU quality of care. Therefore, Pediatric Index of Mortality 3 seems a better choice for use in clinical trials with 90-day mortality as primary outcome.

Aplicación de un programa preventivo de salud bucal en escuelas primarias mexicanas / Application of an oral health prevention program in Mexican elementary schools

Introducción: la alta prevalencia de enfermedades bucales en los escolares, tiene un impacto importante en su salud, lo que ha generado la necesidad de desarrollar programas y estrategias a nivel de políticas públicas para su control. Objetivo: evaluar el Programa de Salud Bucal en alumnos de escuelas primarias mexicanas. Métodos: estudio de intervención comunitaria en dos escuelas primarias públicas de la Secretaria de Salud, en la Delegación de Tlalpan, Ciudad de México. Se incluyeron 111 alumnos de quinto grado de primaria, 53 pertenecientes a la escuela primaria pública del turno matutino Río Pánuco como grupo de intervención con aplicación del Programa de Salud Bucal (grupo de trabajo), y 58 correspondientes a la escuela Ignacio Rodríguez Galván, sin intervensión (grupo control). A todos los alumnos se les realizó determinación de los índices de dientes cariados, perdidos y obturados temporales, y permanentes, y el índice periodontal comunitario. Para el análisis estadístico inferencial se utilizó U de Mann-Whitney y chi cuadrado de Pearson, con nivel de significancia 0,05. Se empleó el programa estadístico SPSS versión 22. Resultados: el promedio de edad de los niños de la escuela con intervención fue de 10,9 y de la escuela control de 10,8. En el índice para dentición temporal, el promedio de dientes cariados fue de 0,49 (IC 95 por ciento 0,07-0,91) para la escuela que intervino en el programa, y de 1,10 (IC 95 por ciento 0,70-1,51) para escuela sin intervención, con diferencias estadísticas significativas (p= 0,003). En el índice periodontal comunitario, se obtuvo 92,4 por ciento de escolares sanos para la escuela que intervino en el programa, y de 70,68 por ciento para la escuela sin intervención, con diferencia estadística significativa (p= 0,003). Conclusiones: los resultados muestran que el programa es efectivo ya que la población intervenida presenta mejores condiciones de salud bucal que los escolares del grupo control, diferencia esta clínicamente relevante(AU)

Introduction: the high prevalence of oral disease among school children has a great impact on their health, hence the need to develop control programs and strategies at public policy level. Objective: evaluate the Oral Health Program for Mexican elementary school children. Methods: a community intervention study was conducted in two public elementary schools from the Ministry of Health in the borough of Tlalpan, Mexico City. The study sample was composed of 111 fifth grade students, 53 from Río Pánuco morning session public school as intervention group with application of the oral health program (work group), and 58 from Ignacio Rodríguez Galván school, without intervention (control group). All students were examined to determine the rate of decay, loss, temporary fillings and permanent teeth, and the community periodontal index. Inferential statistical analysis was based on Mann-Whitney U and Pearson's chi-square, with a significance level of 0.05. Data were processed with the statistical software SPSS version 22. Results: mean age was 10.9 at the intervention school and 10.8 at the control school. With respect to the primary dentition index, the average of decayed teeth was 0.49 (CI 95 percent 0.07-0.91) for the school with the intervention program, and 1.10 (CI 95 percent 0.70-1.51) for the school without intervention, with significant statistical differences (p= 0.003). As to the community periodontal index, 92.4 percent of the children were healthy at the school with the intervention program, and 70.68 percent were healthy at the school without intervention, with a significant statistical difference (p= 0.003). Conclusions: results show that the program is effective, since the school children intervened are in better oral health conditions than those in the control group, and the difference is clinically relevant(AU)

Aplicación de un programa preventivo de salud bucal en escuelas primarias mexicanas / Application of an oral health prevention program in Mexican elementary schools

Introducción: la alta prevalencia de enfermedades bucales en los escolares, tiene un impacto importante en su salud, lo que ha generado la necesidad de desarrollar programas y estrategias a nivel de políticas públicas para su control. Objetivo: evaluar el Programa de Salud Bucal en alumnos de escuelas primarias mexicanas. Métodos: estudio de intervención comunitaria en dos escuelas primarias públicas de la Secretaria de Salud, en la Delegación de Tlalpan, Ciudad de México. Se incluyeron 111 alumnos de quinto grado de primaria, 53 pertenecientes a la escuela primaria pública del turno matutino Río Pánuco como grupo de intervención con aplicación del Programa de Salud Bucal (grupo de trabajo), y 58 correspondientes a la escuela Ignacio Rodríguez Galván, sin intervensión (grupo control). A todos los alumnos se les realizó determinación de los índices de dientes cariados, perdidos y obturados temporales, y permanentes, y el índice periodontal comunitario. Para el análisis estadístico inferencial se utilizó U de Mann-Whitney y chi cuadrado de Pearson, con nivel de significancia 0,05. Se empleó el programa estadístico SPSS versión 22. Resultados: el promedio de edad de los niños de la escuela con intervención fue de 10,9 y de la escuela control de 10,8. En el índice para dentición temporal, el promedio de dientes cariados fue de 0,49 (IC 95 por ciento 0,07-0,91) para la escuela que intervino en el programa, y de 1,10 (IC 95 por ciento 0,70-1,51) para escuela sin intervención, con diferencias estadísticas significativas (p= 0,003). En el índice periodontal comunitario, se obtuvo 92,4 por ciento de escolares sanos para la escuela que intervino en el programa, y de 70,68 por ciento para la escuela sin intervención, con diferencia estadística significativa (p= 0,003). Conclusiones: los resultados muestran que el programa es efectivo ya que la población intervenida presenta mejores condiciones de salud bucal que los escolares del grupo control, diferencia esta clínicamente relevante(AU)

Introduction: the high prevalence of oral disease among school children has a great impact on their health, hence the need to develop control programs and strategies at public policy level. Objective: evaluate the Oral Health Program for Mexican elementary school children. Methods: a community intervention study was conducted in two public elementary schools from the Ministry of Health in the borough of Tlalpan, Mexico City. The study sample was composed of 111 fifth grade students, 53 from Río Pánuco morning session public school as intervention group with application of the oral health program (work group), and 58 from Ignacio Rodríguez Galván school, without intervention (control group). All students were examined to determine the rate of decay, loss, temporary fillings and permanent teeth, and the community periodontal index. Inferential statistical analysis was based on Mann-Whitney U and Pearson's chi-square, with a significance level of 0.05. Data were processed with the statistical software SPSS version 22. Results: mean age was 10.9 at the intervention school and 10.8 at the control school. With respect to the primary dentition index, the average of decayed teeth was 0.49 (CI 95 percent 0.07-0.91) for the school with the intervention program, and 1.10 (CI 95 percent 0.70-1.51) for the school without intervention, with significant statistical differences (p= 0.003). As to the community periodontal index, 92.4 percent of the children were healthy at the school with the intervention program, and 70.68 percent were healthy at the school without intervention, with a significant statistical difference (p= 0.003). Conclusions: results show that the program is effective, since the school children intervened are in better oral health conditions than those in the control group, and the difference is clinically relevant(AU)

Estado de dentición y su impacto en la calidad de vida en adultos mayores / State of dentition and its impact on quality of life in the elderly

Resumen Introducción y objetivo: La mayoría de adultos mayores enfrentan problemas para comer y relacionarse con los demás debido a las alteraciones que presentan en la boca, lo que afecta su satisfacción y su calidad de vida. Determinar el estado de la dentición de los alumnos de la Universidad de la Tercera Edad de la Ciudad de México y asociarlo con la calidad de vida. Material y métodos: Estudio transversal descriptivo. Se realizó evaluación clínica mediante el registro CPOD y presencia de edentulismo. Se aplicó el cuestionario Perfil de Impacto de Salud Bucal OHIP-14, para evaluar calidad de vida. El análisis estadístico se realizó con el coeficiente de correlación de Spearman, nivel de significancia de 0,05, programa SPSS. Versión 22. Resultados: Se incluyeron 100 adultos mayores con promedio de edad de 68,2. ± 5,02. En el índice CPOD, se obtuvo una media de 1,04 para dientes cariados, 7,9 para dientes perdidos y 4,9 para dientes obturados. En el perfil de impacto, las dimensiones mayormente afectadas fueron la limitación funcional con media de 2,33 y el malestar psicológico con 1,67. Al correlacionar el estado de dentición y la calidad de vida se obtuvo coeficiente de correlación de Spearman de 0,312 con una p= 0,002. Conclusiones: Los resultados obtenidos en esta población, reflejan un mejor estado de dentición que los reportados por otros autores, se obtuvo asociación estadística pero con baja correlación entre el estado de dentición y la mayoría de las dimensiones de calidad de vida.

Abstract Introduction and objectives: Most elderly face trouble to eat and to relate with others, due to alterations presented in the mouth, which affects their satisfaction and quality of life.To determine the condition of the dentition of the students of a University of the Third Age of the City of Mexico and to associate it with the quality of life. Material and methods: Descriptive cross-sectional study. Clinical evaluation was performed through the DMFT registry and presence of Edentulous. Oral health impact profile OHIP-14 was applied to evaluate quality of life. Statistical Analysis with Spearman correlation coefficient of 0.05. SPSS v. 22. Results: 100 elderly were included with an average age of 68.2± 5.02. In the DMFT index a 1.04 median for carious teeth was obtained, 7.9 for lost teeth and 4.9 for filled teeth. At the profile impact, the most affected dimensions were the functional limitation with a 2.33 median, psychological discomfort with 1.67. By correlating dentition status and quality of life, Pearson correlation coefficient of 0.312 with p=0.002 was obtained. Conclusions: The results obtained in this population, reflect a better dentition state than those reported by other authors, statistical association was obtained but with a low correlation between the state of dentition and most of the dimensions of quality of life.

PICU Volume and Outcome: A Severity-Adjusted Analysis.

OBJECTIVES: To determine the relationship between PICU volume and severity-adjusted mortality in a large, national dataset. DESIGN: Retrospective cohort study. SETTING: The VPS database (VPS, LLC, Los Angeles, CA), a national multicenter clinical PICU database. PATIENTS: All patients with discharge dates between September 2009 and March 2012 and valid Pediatric Index of Mortality 2 and Pediatric Risk of Mortality III scores, who were not transferred to another ICU and were seen in an ICU that collected at least three quarters of data. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Anonymized data received included ICU mortality, hospital and patient demographics, and Pediatric Index of Mortality 2 and Pediatric Risk of Mortality III scores. PICU volume/quarter was determined (VPS sites submit data quarterly) per PICU and was divided by 100 to assess the impact per 100 discharges per quarter (volume). A mixed-effects logistic regression model accounting for repeated measures of patients within ICUs was performed to assess the association of volume on severity-adjusted mortality, adjusting for patient and unit characteristics. Multiplicative interactions between volume and severity of illness were also modeled. We analyzed 186,643 patients from 92 PICUs, with an overall ICU mortality rate of 2.6%. Volume ranged from 0.24 to 8.89 per ICU per quarter; the mean volume was 2.61. The mixed-effects logistic regression model found a small but nonlinear relationship between volume and mortality that varied based on the severity of illness. When severity of illness is low, there is no clear relationship between volume and mortality up to a Pediatric Index of Mortality 2 risk of mortality of 10%; for patients with a higher severity of illness, severity of illness-adjusted mortality is directly proportional to a unit's volume. CONCLUSIONS: For patients with low severity of illness, ICU volume is not associated with mortality. As patient severity of illness rises, higher volume units have higher severity of illness-adjusted mortality. This may be related to differences in quality of care, issues with unmeasured confounding, or calibration of existing severity of illness scores.

Monitoring Dead Space in Mechanically Ventilated Children: Volumetric Capnography Versus Time-Based Capnography.

BACKGROUND: Volumetric capnography dead-space measurements (physiologic dead-space-to-tidal-volume ratio [VD/VT] and alveolar VD/VT) are considered more accurate than the more readily available time-based capnography dead-space measurement (end-tidal alveolar dead-space fraction [AVDSF]). We sought to investigate the correlation between volumetric capnography and time-based capnography dead-space measurements. METHODS: This was a single-center prospective cohort study of 65 mechanically ventilated children with arterial lines. Physiologic VD/VT, alveolar VD/VT, and AVDSF were calculated with each arterial blood gas using capnography data. RESULTS: We analyzed 534 arterial blood gases from 65 children (median age 4.9 y, interquartile range 1.7-12.8). The correlation between physiologic VD/VT and AVDSF (r = 0.66, 95% CI 0.59-0.72) was weaker than the correlation between alveolar VD/VT and AVDSF (r = 0.8, 95% CI 0.76-0.85). The correlation between physiologic VD/VT and AVDSF was weaker in children with low PaO2 /FIO2 (< 200 mm Hg), low exhaled VT (< 100 mL), a pulmonary reason for mechanical ventilation, or large airway VD (> 3 mL/kg). All 3 dead-space measurements were highly correlated (r > 0.7) in children without hypoxemia (PaO2 /FIO2 > 300 mm Hg), mechanically ventilated for a neurologic or cardiac reason, or on significant inotropes or vasopressors. CONCLUSIONS: In mechanically ventilated children without significant hypoxemia or with cardiac output-related dead-space changes, physiologic VD/VT was highly correlated with AVDSF and alveolar VD/VT. In children with significant hypoxemia, physiologic VD/VT was poorly correlated with AVDSF. Alveolar VD/VT and AVDSF correlated well in most tested circumstances. Therefore, AVDSF may be useful in most children for alveolar dead-space monitoring.

Pediatric Index of Cardiac Surgical Intensive Care Mortality Risk Score for Pediatric Cardiac Critical Care.

OBJECTIVE: Comparison of clinical outcomes is imperative in the evaluation of healthcare quality. Risk adjustment for children undergoing cardiac surgery poses unique challenges, due to its distinct nature. We developed a risk-adjustment tool specifically focused on critical care mortality for the pediatric cardiac surgical population: the Pediatric Index of Cardiac Surgical Intensive care Mortality score. DESIGN: Retrospective analysis of prospectively collected pediatric critical care data. SETTING: Pediatric critical care units in the United States. PATIENTS: Pediatric cardiac intensive care surgical patients. INTERVENTIONS: Prospectively collected data from consecutive patients admitted to ICUs were obtained from The Virtual PICU System (VPS, LLC, Los Angeles, CA), a national pediatric critical care database. Thirty-two candidate physiologic, demographic, and diagnostic variables were analyzed for inclusion in the development of the Pediatric Index of Cardiac Surgical Intensive care Mortality model. Multivariate logistic regression with stepwise selection was used to develop the model. MEASUREMENTS AND MAIN RESULTS: A total of 16,574 cardiac surgical patients from the 55 PICUs across the United States were included in the analysis. Thirteen variables remained in the final model, including the validated Society of Thoracic Surgeons-European Association of Cardio-Thoracic Surgery Congenital Heart Surgery Mortality (STAT) score and admission time with respect to cardiac surgery, which identifies whether the patient underwent the index surgical procedure before or after admission to the ICU. Pediatric Index of Cardiac Surgical Intensive Care Mortality (PICSIM) performance was compared with the performance of Pediatric Risk of Mortality-3 and Pediatric Index of Mortality-2 risk of mortality scores, as well as the STAT score and STAT categories by calculating the area under the curve of the receiver operating characteristic from a validation dataset: PICSIM (area under the curve = 0.87) performed better than Pediatric Index of Mortality-2 (area under the curve = 0.81), Pediatric Risk of Mortality-3 (area under the curve = 0.82), STAT score (area under the curve = 0.77), STAT category (area under the curve = 0.75), and Risk Adjustment for Congenital Heart Surgery-1 (area under the curve = 0.74). CONCLUSIONS: This newly developed mortality score, PICSIM, consisting of 13 risk variables encompassing physiology, cardiovascular condition, and time of admission to the ICU showed better discrimination than Pediatric Index of Mortality-2, Pediatric Risk of Mortality-3, and STAT score and category for mortality in a multisite cohort of pediatric cardiac surgical patients. The introduction of the variable "admission time with respect to cardiac surgery" allowed prediction of mortality when patients are admitted to the ICU either before or after the index surgical procedure.

Evidence-Based Pediatric Outcome Predictors to Guide the Allocation of Critical Care Resources in a Mass Casualty Event.

OBJECTIVE: ICU resources may be overwhelmed by a mass casualty event, triggering a conversion to Crisis Standards of Care in which critical care support is diverted away from patients least likely to benefit, with the goal of improving population survival. We aimed to devise a Crisis Standards of Care triage allocation scheme specifically for children. DESIGN: A triage scheme is proposed in which patients would be divided into those requiring mechanical ventilation at PICU presentation and those not, and then each group would be evaluated for probability of death and for predicted duration of resource consumption, specifically, duration of PICU length of stay and mechanical ventilation. Children will be excluded from PICU admission if their mortality or resource utilization is predicted to exceed predetermined levels ("high risk"), or if they have a low likelihood of requiring ICU support ("low risk"). Children entered into the Virtual PICU Performance Systems database were employed to develop prediction equations to assign children to the exclusion categories using logistic and linear regression. Machine Learning provided an alternative strategy to develop a triage scheme independent from this process. SETTING: One hundred ten American PICUs SUBJECTS: : One hundred fifty thousand records from the Virtual PICU database. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The prediction equations for probability of death had an area under the receiver operating characteristic curve more than 0.87. The prediction equation for belonging to the low-risk category had lower discrimination. R for the prediction equations for PICU length of stay and days of mechanical ventilation ranged from 0.10 to 0.18. Machine learning recommended initially dividing children into those mechanically ventilated versus those not and had strong predictive power for mortality, thus independently verifying the triage sequence and broadly verifying the algorithm. CONCLUSION: An evidence-based predictive tool for children is presented to guide resource allocation during Crisis Standards of Care, potentially improving population outcomes by selecting patients likely to benefit from short-duration ICU interventions.

Health and economic outcomes for exenatide once weekly, insulin, and pioglitazone therapies in the treatment of type 2 diabetes: a simulation analysis.

BACKGROUND: Patients with type 2 diabetes (T2DM) are at risk of long-term vascular complications. In trials, exenatide once weekly (ExQW), a GLP-1R agonist, improved glycemia, weight, blood pressure (BP), and lipids in patients with T2DM. We simulated potential effects of ExQW on vascular complications, survival, and medical costs over 20 years versus standard therapies. PATIENTS AND METHODS: The Archimedes model was used to assess outcomes for ~25,000 virtual patients with T2DM (NHANES 1999-2006 [metformin ± sulfonylureas, age 57 years, body mass index 33 kg/m(2), weight 94 kg, duration T2DM 9 years, hemoglobin A1c [A1C] 8.1%]). The effects of three treatment strategies were modeled and compared to moderate-adherence insulin therapy: advancement to high-adherence insulin at A1C ≥ 8% (treat to target A1C < 7%) and addition of pioglitazone (PIO) or ExQW from simulation start. ExQW effects on A1C, weight, BP, and lipids were modeled from clinical trial data. Costs, inflated to represent 2010 $US, were derived from Medicare data, Drugstore.com, and publications. As ExQW was investigational, we omitted ExQW, PIO, and insulin pharmacy costs. RESULTS: By year 1, ExQW treatment decreased A1C (~1.5%), weight (~2 kg), and systolic BP (~5 mmHg). PIO and high-adherence insulin decreased A1C by ~1%, increased weight, and did not affect systolic BP. After 20 years, A1C was ~7% with all strategies. ExQW decreased rates of cardiovascular and microvascular complications more than PIO or high-adherence insulin versus moderate-adherence insulin. Over 20 years, ExQW treatment resulted in increased quality-adjusted life-years (QALYs) of ~0.3 years/person and cost savings of $469/life-year versus moderate adherence insulin. For PIO or high-adherence insulin, QALYs were virtually unchanged, and costs/life-year versus moderate-adherence insulin increased by $69 and $87, respectively. CONCLUSIONS: This long-term simulation demonstrated that ExQW treatment may decrease rates of cardiovascular and some microvascular complications of T2DM. Increased QALYs, and decreased costs were also projected.

Pathology of the testicle after long-termanabolic steroid treatment in a thoroughbread horse from Venezuela

The aim of this study was to describe a case of pathology of the testicle after long-term anabolic steroid treatment in a Thoroughbread horse. Were study an equine Thoroughbread with cryptorchidism from Venezuela, male of 5 years old. With history of lameness chronic and subfertility. Necropsy was performed and samples of testicle tissue were collected. The tissue samples were fixed in formalin and processed by conventional H&E techniques. Additionally, the special staining procedure of Tricromico de Gomory and Blue VonKossa were also carried out. Samples of blood and urine were recollected for toxicological by competitive ELISA. The left testicle was diameter testicle 6cm. and cryptorchidism (testicle right). Macroscopic were observed bilateral fibrosis parenchyma testicle and atrophic. The histological study revealed atrophy of seminiferous tubules and interstitial fibrosis increases in collagen fibres in the lamina propria of seminiferous tubules and testicular interstitium. Lamina propria surrounding atrophic tubules was thickened by an increase in collagen type IV and elastic fibres and by proliferation of bizarre myoid cells. Basal lamina was also thickened but had decreased for collagen type IV. Special stain Tricromico of Gomory (+) showed fibrosis interstitium severed and VonKossa (-) no evidence mineral. Toxicological studies allowed the detection of boldenona and dexamethasone generic in blood and urine samples. To conclude, we detected the presence of pathology of the testicle associated a after long-term anabolic steroid treatment in a Thoroughbred horse.

Efecto del estrés asociado al destete sobre variables clínico-patológicas y la integridad de la mucosa gástrica en potros pura sangre de carrera / Effect of weaning stress on clinical-pathological variables and the gastric mucosa integrity in thoroughbred foals

El destete en los caballos Pura Sangre de carreras (PSC), se realiza regularmente a los seis meses de edad. Esta medida de manejo puede conllevar al desarrollo de estrés post-destete, con todos los potenciales efectos deletéreos que éste puede originar. El objetivo de este trabajo fue investigar el efecto de dos tipos de destete sobre variables clínico-patológicas y hallazgos gastroscópicos, como indicadores de estrés en potros PSC. Se seleccionaron al azar doce potros de seis meses de edad, de diferentes sexos. Seis de los potros fueron separados abruptamente de las madres (grupo A) y permanecieron solos dentro de los puestos o establos. Los seis animales restantes fueron separados de las madres, pero permanecieron en potreros junto a otros potros o yeguas (grupo B). Todos los potros fueron sometidos a examen físico para determinar signos de estrés y ulceras gástricas, antes del destete y 21 días después de éste. Se tomaron muestras sanguíneas para evaluar leucocitos, glicemia y cortisol sérico. También se tomaron muestras de heces para evaluar sangre oculta. La evaluación gastroscópica fue clasificada según la escala propuesta por Macallister. Los indicadores de las variables fueron analizados a través de pruebas estadísticas no paramétricas. Al evaluar los signos clínicos, sólo un potro del grupo A presentó diarrea y bruxismo en la evaluación del cortisol sanguíneo y glicemia entre pre- y post-destete, no hubo diferencias significativas en ninguno de los grupos. El contaje leucocitario fue significativamente (P<0,05) superior después del destete en los potros del grupo A. En el análisis de sangre oculta en heces, los dos grupos de destete resultaron negativos. La evaluación gastroscópica evidenció la presencia de úlceras gástricas en dos potros del grupo A y dos del grupo B.

Tratamiento de las fracturas de tobillo tipo C de Weber: estudio clínico experimental / Treatment of ankle fractures Weber C: clinical experimental study

Se estudió anatómicamente y funcionalmente la influencia de la osteosíntesis en las fracturas tipo C de Weber y su evolución a largo plazo. Para ello se seleccionaron 24 pacientes que fueron divididos en 3 grupos según la altura de la fractura respecto del centro de la sindesmosis y que fueron evaluados clínicamente (en los aspectos objetivos y subjetivos) y radiográficamente, en el prequirúrgico y posquirúrgico mediato e inmediato. En forma paralela se realizó un estudio experimental sobre 6 piezas cadavéricas, con el propósito de estudiar la necesidad mecánica del uso del tornillo suprasindesmal. Se observó que, en los pacientes con fracturas de 0-3,5 cm. por arriba del centro de la sindesmosis, el tornillo suprasindesmal no influye en los resultados y, la reparación del complejo medial permite alcanzar los objetivos buscados. En el grupo de 3,6-7 cm., no es recomendable la utilización conjunta del tornillo suprasindesmal con la reparación del complejo medial y estos casos presentaron peor pronóstico. En el grupo de más de 7 cm., los resultados fueron independientes del tipo de osteosíntesis, pero experimentalmente se determinó la necesidad del suplemento con tornillo suprasindesmal. Comprobamos también que los cambios degenerativos eran mayores en las fracturas más cercanas a la articulación

Tratamiento de las fracturas de tobillo tipo C de Weber: estudio clínico experimental / Treatment of ankle fractures Weber C: clinical experimental study

Se estudió anatómicamente y funcionalmente la influencia de la osteosíntesis en las fracturas tipo C de Weber y su evolución a largo plazo. Para ello se seleccionaron 24 pacientes que fueron divididos en 3 grupos según la altura de la fractura respecto del centro de la sindesmosis y que fueron evaluados clínicamente (en los aspectos objetivos y subjetivos) y radiográficamente, en el prequirúrgico y posquirúrgico mediato e inmediato. En forma paralela se realizó un estudio experimental sobre 6 piezas cadavéricas, con el propósito de estudiar la necesidad mecánica del uso del tornillo suprasindesmal. Se observó que, en los pacientes con fracturas de 0-3,5 cm. por arriba del centro de la sindesmosis, el tornillo suprasindesmal no influye en los resultados y, la reparación del complejo medial permite alcanzar los objetivos buscados. En el grupo de 3,6-7 cm., no es recomendable la utilización conjunta del tornillo suprasindesmal con la reparación del complejo medial y estos casos presentaron peor pronóstico. En el grupo de más de 7 cm., los resultados fueron independientes del tipo de osteosíntesis, pero experimentalmente se determinó la necesidad del suplemento con tornillo suprasindesmal. Comprobamos también que los cambios degenerativos eran mayores en las fracturas más cercanas a la articulación