Association Between Changes in Sleep, Nap Duration and Bone Mineral Density in Mexican Adults.

Studies have found associations between sleep, nap duration, and bone mineral density (BMD). However, the longitudinal relationship between sleep, nap duration, and BMD has not been explored. We evaluated the association between the change in sleep and nap duration and BMD in Mexican adults. Data come from 1,337 adult participants of the Health Workers Cohort Study (341 were men and 996 were women, including 450 women < 45 years old and 546 ≥ 45 years old), with two study waves. At each wave, sleep and nap duration was assessed using self-administered questionnaires and BMD in g/cm2 was determined by dual X-ray absorptiometry. We used fixed-effect regression models stratified by sex and adjusted for BMI, diet, physical activity, vitamin supplements, and hormone replacement therapy. Women who changed from < 7 to ≥ 7 h/day of sleep from baseline to follow-up were associated with increases in the total hip (ß = 0.012 g/cm2; 95% CI: 0.002, 0.022) and lumbar spine BMD (ß = 0.024 g/cm2; 95% CI: 0.009, 0.039). Furthermore, most of these associations were observed in women ≥ 45 years. For women, a changing from 0 to > 60 min/day of napping was associated with a significant increase in total hip BMD of 0.012 g/cm2 (95% CI: 0.004, 0.024) and lumbar spine BMD of 0.027 g/cm2 (95% CI: 0.009, 0.045). No significant associations were observed for men. Our results suggest that increased sleep and nap duration are associated with gains in BMD in Mexican women, emphasizing sleep's role in promoting bone health and supporting established recommendations.

Outbreak of Fusarium solani Meningitis in Immunocompetent Persons Associated With Neuraxial Blockade in Durango, Mexico, 2022-2023.

Background: Fungal meningitis can be associated with epidural anesthesia procedures. Fusariosis is a rare infection typically affecting immunocompromised patients and rarely causes meningitis. During 2022-2023, public health officials responded to a large outbreak of Fusarium solani meningitis associated with epidural anesthesia in Durango, Mexico. Methods: The public health response and epidemiological and clinical features of patients affected by this outbreak were described. Coordinated actions were addressed to identify the etiological agent, determine its drug susceptibility, develop diagnostic tests, and implement clinical and epidemiological protocols. Retrospective analyses of clinical variables and outcomes were performed to determine association with better patient survival. Results: A total of 1801 persons exposed to epidural anesthesia were identified, of whom 80 developed meningitis. Fusarium solani was found in 3 brain biopsies and showed susceptibility to voriconazole and amphotericin B. After F solani polymerase chain reaction (PCR) implementation, 57 patients with meningitis were PCR-screened, and 31 (38.8%) had a positive result. Most patients were female (95%), and cesarean section was the most common surgical procedure (76.3%). The case fatality rate was 51.3% (41 patients) and the median hospitalization duration was 39.5 days (interquartile range, 18-86 days). Seventy-one patients (88.8%) received voriconazole/amphotericin B and 64 subjects (80%) additionally received steroids. Cox regression analysis showed an increased lethality risk in patients who received antifungal treatment after 5 days (hazard ratio, 2.1 [95% confidence interval, 1.01-4.48], P < .05). Conclusions: The F solani meningitis outbreak in Durango was an unprecedented medical challenge. Timely treatment and effective healthcare management were associated with better survival outcomes.

[The track of the clinical researcher]. / El camino del investigador clínico.

In this issue, the students of the Maestría en Ciencias de la Salud Program, who are generally doctors, publish their work in the format of architectural design. The architectural design, allows to demonstrate in a schematic way, the objective, basal state, maneuver and outcome of their investigations. In this issue of the Revista Médica del IMSS, architectural design is used explicitly for the first time in a scientific publication. This innovation was achieved thanks to the collaboration of the editors and students of the Maestría en Ciencias de la Salud Program.

En este número los estudiantes de la Maestría en Ciencias de la Salud, los cuales, en general, son médicos y publican sus trabajos con el formato del diseño arquitectónico. El diseño arquitectónico permite mostrar de forma esquemática, el objetivo, estado basal, maniobra y desenlace de sus investigaciones. En este número de la Revista Médica del IMSS se usa por primera vez de forma explícita el diseño arquitectónico en una publicación científica. Esta innovación se logró gracias a la colaboración de los editores y estudiantes de la Maestría de Ciencias de la Salud.

[Comment on article: "Laboratories as predictors of length of hospital stay in patients with pneumonia"]. / Comentario al artículo: "Laboratorios como predictores del tiempo de estancia hospitalaria en pacientes con neumonía".

Laboratory studies are a useful tool for both diagnosis and prognosis of pathologies, especially in the emergency room. In the article they seek to establish an association between laboratory studies and hospital stay in patients with community-acquired pneumonia. Some suggestions are made to improve the structured review of the article.

Los estudios de laboratorio son una herramienta útil tanto para el diagnóstico como para el pronóstico de las patologías, sobre todo en el área de urgencias. En el artículo se busca establecer una asociación entre los estudios de laboratorio y la estancia intrahospitalaria en pacientes con neumonía adquirida en la comunidad. Se realizan algunas sugerencias a fin de mejorar la revisión estructurada del artículo.

[Severe post-COVID-19 dialysis dependence and inpatient acute kidney injury]. / Dependencia a diálisis posterior a COVID-19 grave y lesión renal aguda intrahospitalaria.

Background: COVID-19 challenged our health system, within the broad clinical spectrum acute kidney injury was presented as a catastrophic event, acute kidney injury and the risk of dependency after dialysis constitute a clinical problem with high repercussions in the funcionality. Objective: To identify risk factors for dialysis dependence after acute kidney injury from COVID-19. Material and methods: A retrospective observational cohort study was carried out at the Hospital de Especialidades del Centro Médico Nacional Siglo XXI, of the Mexican Institute of Social Security, from March 2020 to March 2021. 317 patients were included, we performed descriptive statistics, we compared differences between the stages of acute kidney injury, finding a difference in obesity with a frequency of 2.2% in stage 1, 20.82% stage 2 and 14.51% stage 3, with p value = 0.018. Results: We found dialysis dependence one year after hospital-acquired acute kidney injury induced by COVID-19 in 58 patients (18.9%), we analyzed by KDIGO stage, in those patients who had AKI KDIGO 1 (2.83%) it depended on dialysis at one year, in the KDIGO stage 2 (3.78%), in the KDIGO stage 3 (11.67%). Conclusions: Our study allowed us to identify that the risk factors associated with dialysis dependence are: male gender, type 2 diabetes mellitus, obesity, cardiovascular disease.

Introducción: la COVID-19, retó a nuestro sistema de salud, dentro del amplio espectro clínico la lesión renal aguda se presentó como un evento catastrófico, la lesión renal aguda y el riesgo de dependencia posterior a diálisis constituye un problema clínico con alta repercusión en la funcionalidad. Objetivo: identificar los factores de riesgo para la dependencia a diálisis posterior a lesión renal aguda por COVID-19. Material y métodos: se realizó un estudio de cohorte observacional retrospectivo en el Hospital de Especialidades del Centro Médico Nacional Siglo XXI, del Instituto Mexicano del Seguro Social, del periodo de marzo del 2020 a marzo del 2021. Se incluyeron 317 pacientes, realizamos estadística descriptiva, comparamos diferencias entre los estadios de lesión renal aguda encontrando diferencia en obesidad con frecuencia de 2.2% en estadio 1, de 20.82% estadio 2 y de 14.51% estadio 3, con valor p = 0.018. Resultados: encontramos la dependencia a diálisis a un año posterior a lesión renal aguda intrahospitalaria inducida por COVID-19 en 58 pacientes (18.9%), analizamos por estadio de KDIGO, en aquellos pacientes que cursaron con LRA KDIGO 1 (2.83%) dependió de diálisis a un año, en el estadio KDIGO 2 (3.78%), en el estadio KDIGO 3 (11.67%). Conclusiones: nuestro estudio permitió identificar que los factores de riesgo que se asocian con dependencia a diálisis son: sexo masculino, diabetes mellitus tipo 2, obesidad, enfermedad cardiovascular.

[Factors associated with benzodiazepines dependence in insomnia patients]. / Factores asociados a la dependencia a benzodiacepinas en pacientes con insomnio.

Background: The use of benzodiazepines as a treatment for insomnia can have side effects such as impaired coordination causing falls in adults and even dependence. Objective: To assess the factors associated with dependence on benzodiazepines in patients with insomnia. Methods: Observational, cross-sectional, prospective, and analytical study, at the first level of care. Patients older than 18 years with a diagnosis of insomnia and a benzodiazepine prescription were selected. The dependency was measured with the International Neuropsychiatric Interview. Results: 107 patients were included. Median age 67 years, predominantly female (72%), 74% attended secondary school or more, 71% had more than 3 years of diagnosis, 84% used clonazepam. The 54% presented dependency. In the bivariate analysis, schooling RM 0.392 (95%CI: 0.15-0.96) p = 0.038, moderate and severe clinical insomnia RM 3.618 (95%CI: 1.44-9.08) p = 0.005 and more than 3 years of diagnosis RM 2.428 (95%CI: 1.03-5.71) p = 0.040. In the multivariate model, schooling (p = 0.084), years of diagnosis (p = 0.062) and frequency of consumption (p = 0.065) obtained an R2 of 0.13. Conclusions: Primary schooling showed a lower risk of presenting dependence on benzodiazepines. The risk was increased in those with more than 3 years of diagnosis, and in those with moderate and severe insomnia.

Introducción: el uso de benzodiacepinas como tratamiento para el insomnio puede tener efectos secundarios, como el deterioro de la coordinación que puede provocar caídas en adultos e, incluso, dependencia. Objetivo: evaluar los factores asociados a la dependencia a benzodiacepinas en pacientes con insomnio. Material y métodos: estudio observacional, transversal, prospectivo y analítico, llevado a cabo en el primer nivel de atención. Se seleccionaron pacientes mayores de 18 años con diagnóstico de insomnio y prescripción de benzodiacepina. La dependencia se midió con la Entrevista Neuropsiquiátrica Internacional. Resultados: se incluyeron 107 pacientes, la mediana de edad fue de 67 años, con predominio del sexo femenino (72%), el 74% cursó educación secundaria o más, el 71% tenía más de tres años con diagnóstico de insomnio, el 84% usaba clonazepan. El 54% presentó dependencia. En el análisis bivariado, la escolaridad primaria mostró una razón de momios (RM) de 0.392 (IC95%: 0.15-0.96), p = 0.038; el insomnio clínico moderado y grave RM de 3.618 (IC95%: 1.44-9.08) p = 0.005, y más de tres años de diagnóstico con una RM de 2.428 (IC95%: 1.03-5.71) p = 0.040. En el modelo multivariado, la escolaridad (p = 0.084), los años de diagnóstico (p = 0.062) y la frecuencia de consumo (p = 0.065) obtuvieron una R2 de 0.13. Conclusiones: los pacientes con escolaridad primaria mostraron un menor riesgo de presentar dependencia a benzodiacepinas. El riesgo se incrementó en los pacientes con más de tres años de diagnóstico y en aquellos con insomnio moderado y grave.

[Efficacy and safety of atorvastatin in major cardiovascular events: Meta-analysis]. / Eficacia y seguridad de la atorvastatina en eventos cardiovasculares mayores: metaanálisis.

Introduction: Atorvastatin has been used in the management of dyslipidemia and little is known about the efficacy and safety of high-dose atorvastatin administration for secondary prevention of Major Cardiovascular Events (MACE). Objective: To evaluate the impact of high-dose atorvastatin on secondary prevention of MACE and adverse events. Material and methods: A systematic review and meta-analysis of Pubmed, Embase, Bireme and Cochrane Library Plus databases was performed, with a time scope from 1990 to July 2022. Six randomized clinical trials were included with a total of 29,333 patients who were treated with 80 mg, 10 mg or placebo doses of Atorvastatin where the main outcomes evaluated were Major Cardiovascular Events (MACE), mortality and treatment safety. Results: In the comparative study between the use of Atorvastatin 80 mg and other therapies, a relative risk (RR) of 0.8 (95%CI 0.69-0.92) was found, representing a 20% reduction in risk (RRR) and a number needed to treat (NNT) of 30-55. In the analysis of adverse effects, an RR of 2.37 (95% CI 0.86-6.53) and a number needed to harm (NNH) of 14-19 were observed. The use of 80 mg atorvastatin is associated with similar adverse events at lower doses. Conclusions: The use of atorvastatin 80 mg is effective in the secondary prevention of Major Cardiovascular Event (MACE). The drug has adverse events that should be taken into account in secondary prevention.

Introducción: la atorvastatina ha sido usada en el manejo de la dislipidemia y se conoce poco sobre la eficacia y seguridad de la administración de atorvastatina en altas dosis para la prevención secundaria de eventos cardiovasculares mayores (MACE). Objetivo: evaluar el impacto de altas dosis de atorvastatina en la prevención secundaria de MACE y eventos adversos. Material y métodos: se realizó una revisión sistemática y un metaanálisis de las bases de datos Pubmed, Embase, Bireme y Cochrane Library Plus, con un alcance temporal de 1990 a julio de 2022. Se incluyeron seis ensayos clínicos aleatorios con un total de 29,333 pacientes que fueron tratados con dosis de 80 mg, 10 mg o placebo de Atorvastatina donde los resultados principales evaluados fueron los eventos cardiovasculares mayores (MACE), la mortalidad y la seguridad del tratamiento. Resultados: en el estudio comparativo entre el uso de Atorvastatina de 80 mg y otras terapias, se encontró un riesgo relativo (RR) de 0.8 (IC95%: 0.69-0.92), lo que representa una reducción del 20% en el riesgo (RRR) y un número necesario a tratar (NNT) de 30 a 55. En el análisis de los efectos adversos, se observó un RR de 2.37 (IC95%: 0.86-6.53) y un número necesario a dañar (NNH) de 14 a 19. El uso de atorvastatina de 80 mg se asocia con eventos adversos similares a dosis menores. Conclusiones: el uso de atorvastatina de 80 mg es efectivo en la prevención secundaria de evento cardiovascular mayor (MACE). El medicamento tiene eventos adversos que deben de tomarse en cuenta en la prevención secundaria.

[Effect of weight gain on the development of gestational diabetes]. / Efecto de la ganancia ponderal en el desarrollo de diabetes gestacional.

Background: Gestational diabetes mellitus (GDM) refers to diabetes diagnosed in the second or third trimester of pregnancy. Assessing the weight gain in each pregnant women's appointment is a common task of primary care during their visit. However, the implications of this increase in weight for the development of GDM are unknown. Objective: Evaluate if the greater than expected weight gain (HEWG) in pregnancy is a risk factor for the development of GDM. Methods: Analytical, observational, longitudinal, retrolective study, which included pregnant women between 15 and 40 years of age with complete follow-up of the preg-nancy with > 2 prenatal check-ups, somatometry and complete medical history was made. During follow-up, the GPME was determined. Odds ratio (OR) and 95% confi-dence intervals (95% CI) were calculated. Variables with significance were entered into a multiple logistic regression model (MLR), where the dependent variable was DMG. The sample size calculation was for convenience. Results: 1000 pregnant women with a median age of 28 years were included. In the MLR The pre-gestational body mass index (BMI) with overweight had an RM of 1.3 (95% CI 0.86-1.98), BMI with obesity an OR of 2.57 (95% CI 1.6-4.14), the HEWG during pregnancy had an OR 1.14 95% CI (0.71-1.81), Age> 30 years shows an RM of 2.24 (95% CI 1.55-3.25). Conclusions: HEWG during pregnancy is not an independent risk factor for the devel-opment of GDM. The main ones are age> 30 years and pre-gestational obesity.

Introducción: la diabetes mellitus gestacional (DMG) se refiere a la diabetes diagnosti-cada a partir del segundo trimestre del embarazo. Evaluar el incremento de peso de mu-jeres embarazadas es una labor habitual en la consulta del primer nivel de atención. Sin embargo, se desconocen las implicaciones que tiene este incremento ponderal para el desarrollo de DMG. Objetivo: evaluar si la ganancia ponderal mayor a la esperada (GPME) en el embarazo es factor de riesgo para el desarrollo de DMG. Métodos: estudio analítico, observacional, longitudinal, retrolectivo, que incluyó a em-barazadas de 15 a 40 años con seguimiento completo del embarazo con más de dos consultas de control prenatal, somatometría e historia clínica completa. Durante el se-guimiento se determinó la GPME. Se calculó razón de momios (RM) e intervalos de confianza del 95% (IC95%). Las variables con significancia se ingresaron a un modelo de regresión logística múltiple (RLM), en donde la variable de desenlace fue DMG. Resultados: se incluyeron a 1000 embarazadas con mediana de edad de 28 años. En la RLM el índice de masa corporal (IMC) pre-gestacional con sobrepeso tuvo una RM de 1.3 (IC95%: 0.86-1.98), IMC con obesidad una RM de 2.57 (IC95%: 1.6-4.14), la GPME durante el embarazo tuvo una RM de 1.14 (IC95%: 0.71-1.81) y la edad > 30 años una RM de 2.24 (IC95%: 1.55-3.25). Conclusiones: la GPME durante el embarazo no es un factor de riesgo independiente para el desarrollo de DMG. Los principales son la edad >30 años y la obesidad preges-tacional.

[Impact of attend to day care associated with healthy weight in infants and preschoolers]. / Impacto del cuidado infantil en guarderías asociado con peso saludable en lactantes y preescolares.

Background: Being overweight affects millions of infants and preschoolers in the world, affecting their quality and life expectancy. Exposure to day care centers may play an important role in preventing unhealthy weight (UW). Objective: To point out the prevalence and association of day care exposure and other factors associated with UW in infants and preschoolers. Methods: An analytical cross-sectional study was carried out. Infant population aged 6-47 months without comorbidities that compromised their nutritional status were included, and those with formal childcare different from the selected day care were excluded. Exposure to day care, and other factors (perinatal, physical activity, nutritional, and familiar) were evaluated. A z score > 1 SD was considered UW. Prevalence, odds ratios (OR), 95% confidence intervals (95%CI) and adjusted RM by low birth weight, initiation of complementary feeding, consumption of sugary drinks, daytime naps, maternal nutritional status, and family income quintile through logistic regression. Results: The overall prevalence of UW was 17.84% (95%CI: 14.93-21.16), 11.84 (95%CI: 8.54-16.14) for children exposed to day care, and 23.78% (95%CI: 19.21-29.02) in unexposed infant population, showing significant differences between both prevalences (p < 0.001). The adjusted OR for UW presentation was 0.39 (95% CI: 0.23-0.66). Conclusions: Exposure to IMSS day care has shown to be a possible protective environment against the development of a UW.

Introducción: el sobrepeso afecta a millones de lactantes y preescolares en el mundo afectando su calidad y esperanza de vida. La exposición a guarderías puede jugar un papel importante para prevenir un peso no saludable (PNS). Objetivo: indicar la prevalencia y la asociación de la exposición a guarderías y otros factores asociados con el PNS en lactantes y preescolares. Métodos: se realizó un estudio transversal analítico. Se incluyó población infantil de 6-47 meses sin comorbilidades que comprometieran su estado nutricional y se excluyeron a aquellos con un cuidado infantil formal diferente al de las guarderías seleccionadas. Se evaluó la exposición a guardería, y otros factores (perinatales, actividad física, nutricionales, y familiares). Se consideró PNS una puntuación z > 1 DE. Se obtuvieron prevalencias, razones de momios (RM), intervalos de confianza del 95% (IC95%) y RM ajustadas por edad, bajo peso al nacer, inicio de la alimentación complementaria, consumo de bebidas azucaradas, siestas diurnas, estado nutricional materno y quintil de ingreso familiar a través de regresión logística. Resultados: la prevalencia general de PNS fue de 17.84% (IC95%:14.93-21.16), 11.84 (IC95%: 8.54-16.14) para la población infantil expuesta a guarderías, y 23.78% (IC95%: 19.21-29.02) en no expuestos, mostrando diferencias significativas entre ambas prevalencias (p < 0.001). La RM ajustada para la presentación de PNS fue de 0.39 (IC95%: 0.23-0.66) para exposición a guardería. Conclusiones: la exposición a guarderías IMSS mostró ser un posible ambiente protector contra el desarrollo de un PNS.

[ROC curves: general characteristics and their usefulness in clinical practice]. / Curvas ROC: características generales y su uso en la práctica clínica.

The use of diagnostic tests to determine the presence or absence of a disease is essential in clinical practice. The results of a diagnostic test may correspond to numerical estimates that require quantitative reference parameters to be transferred to a dichotomous interpretation as normal or abnormal and thus implement actions for the care of a condition or disease. For example, in the diagnosis of anemia it is necessary to define a cut-off point for the hemoglobin variable and create two categories that distinguish the presence or absence of anemia. The method used for this process is the preparation of diagnostic performance curves, better known by their acronym in English as ROC (Receiver Operating Characteristic). The ROC curve is also useful as a prognostic marker, since it allows defining the cut-off point of a quantitative variable that is associated with greater mortality or risk of complications. They have been used in different prognostic markers in COVID-19, such as the neutrophil/lymphocyte ratio and D-dimer, in which cut-off points associated with mortality and/or risk of mechanical ventilation were identified. The ROC curve is used to evaluate the diagnostic performance of a test in isolation, but it can also be used to compare the performance of two or more diagnostic tests and define which one is more accurate. This article describes the basic concepts for the use and interpretation of the ROC curve, the interpretation of an area under the curve (AUC) and the comparison of two or more diagnostic tests.

El uso de pruebas diagnósticas para determinar la presencia o ausencia de una enfermedad es esencial en la práctica clínica. Los resultados de una prueba diagnóstica pueden corresponder a estimaciones numéricas que requieren parámetros cuantitativos de referencia para trasladarse a una interpretación dicotómica como normal o anormal y así, implementar acciones para la atención de una condición o una enfermedad. Por ejemplo, en el diagnóstico de anemia es necesario definir un punto de corte para la variable hemoglobina y crear dos categorías que distingan la presencia o no de anemia. El método utilizado para este proceso es la elaboración de curvas de rendimiento diagnóstico, mejor conocidas por sus siglas en inglés como ROC (Receiver Operating Characteristic). La curva ROC además es útil como marcador pronóstico, ya que permite definir el punto de corte de una variable cuantitativa que se asocia a mayor mortalidad o riesgo de complicaciones. Se han usado en distintos marcadores pronósticos en COVID-19, como el índice neutrófilos/linfocitos y dímero D, en los que se identificaron puntos de corte asociados a mortalidad y/o riesgo de ventilación mecánica. La curva ROC se utiliza para evaluar el rendimiento diagnóstico de una prueba de forma aislada, pero también se puede usar para comparar el rendimiento de dos o más pruebas diagnósticas y definir aquella que es más precisa. En este artículo se describen los conceptos básicos para el uso e interpretación de la curva ROC, la interpretación de un área bajo la curva (ABC) y la comparación de dos o más pruebas diagnósticas.

[Numerical expression of the clinical course of the disease. Data management]. / Expresión numérica del curso clínico de la enfermedad. Manejo de datos.

Data management "behind the scenes" refers to collection, cleaning, imputation, and demarcation; and despite of being indispensable processes, they are usually neglected and thus, generate erroneous information. During the collection are errors: omission of covariates, deviation from the objective, and insufficient quality. The omission of covariates distorts the result attributed to the main manoeuvre. Deviation from the primary objective commonly occurs when the outcome is rare, delayed, or subjective and promotes substitution by non-equivalent surrogate variables. Moreover, insufficient quality occurs due to inadequate instruments, omission of the measurement procedure, or measurements out of context, such as attribution at the wrong time or equivalent. Furthermore, cleaning implies identifying erroneous, extreme, and missing values, which may or may not be imputed, depending on the percentage. The values of the manoeuvre or the outcome are never imputed, nor are patients eliminated due to a lack of values. Finally, the demarcation of each variable seeks to give it a clinical meaning about the outcome, for which a hierarchical sequence of criteria is followed: 1) previous clinical study, 2) expert agreement, 3) clinical judgment of the investigator/investigators, and 4) statistics. Acting without quality controls in data management frequently causes involuntary lies and confuses instead of clarifying.

El manejo de datos "tras bambalinas" se refiere a los procesos de recopilación, limpieza, imputación y demarcación; los cuales, aun siendo indispensables, usualmente suelen ser descuidados, por lo que generan información errónea. Durante la recopilación son errores: omisión de covariables, desvío del objetivo, y calidad insuficiente. La omisión de covariables distorsiona el resultado atribuido a la maniobra principal. El desvío del objetivo primario es común cuando el desenlace es raro, tardado o subjetivo y promueve la sustitución por variables subrogadas no equivalentes. Además, la calidad insuficiente, sucede por instrumentos inadecuados, omisión del procedimiento de medición, o medición fuera de contexto -como atribución a destiempo o equivalente-. Por otro lado, la limpieza implica identificar valores erróneos, extremos y faltantes, que podrán ser o no imputados, dependiendo del porcentaje se imputará comúnmente por la medida de resumen. Nunca se imputan los valores de la maniobra ni del desenlace, ni se eliminan pacientes por falta de valores. Finalmente, la demarcación de cada variable busca un significado clínico en referencia al desenlace, para ello se sigue una secuencia jerárquica de criterios: 1) estudio clínico previo, 2) acuerdo de expertos, 3) juicio clínico del investigador/investigadores y 4) estadística. Actuar sin controles de calidad en el manejo de datos provoca frecuentemente mentiras involuntarias y confunde en lugar de esclarecer.

Breast Cancer in Pregnant Young Women: Clinicopathological Profile, Survival, and Pregnancy Outcomes.

Background Breast cancer is one of the most common cancer types diagnosed during pregnancy; the presence of any neoplasm in pregnant women faces clinical dilemmas and challenges in cancer and pregnancy management. Pregnancy-associated breast cancer (PABC) is defined as breast cancer diagnosed during pregnancy or within one year after delivery. The aim of this study was to describe tumor clinicopathological characteristics and pregnancy outcomes in PABC patients. Materials and methods This is a retrospective cohort assessing PABC patients. Qualitative variables were compared using Fisher's exact test. Kaplan-Meier method was used to calculate survival. Cox regression and logistic regression methods were used to estimate the hazard ratio (HR) and odds ratio (OR), respectively. Results We assessed 16 PABC patients. Women ≤ 35 years of age were mainly diagnosed at advanced stage (88.8%) with ER-negative disease (77.8%). Patients with >4 pathological lymph nodes (25%; p = 0.001) and ER-negative disease (50%; p = 0.646) showed poor five-year overall survival (OS). In the multivariate analysis, nodal involvement was the main predictor associated with poorer OS (HR = 1.4, 90% confidence interval [CI]: 1.14 to 1.8). The following risk factors might influence the risk of preterm delivery: maternal older age, gestational age at diagnosis, and intrauterine exposure to chemotherapy, but an adjusted OR of 0.61 (90% CI: 0.34 to 1), 0.80 (90% CI: 0.66 to 0.9), and 0.013 (90% CI: 0.00 to 0.9), respectively, did not statistically support such an effect. Conclusions Younger women with PABC had a more aggressive pathological profile that might partly explain the poor OS. Obstetrical adverse events related to preterm delivery should be avoided with better planning of specialized strategies.

[Comment on article "Risk factors associated with preterm birth in a second level hospital"]. / Comentario al artículo "Factores de riesgo asociados a parto pretérmino en un hospital de segundo nivel".

Preterm birth is a worldwide problem with a high economic impact and morbimortality in children. Therefore, the literature has focused on finding modifiable factors associated with this entity, such as the study "Risk factors associated with preterm birth in a second level hospital," which concluded that "100% of risk factors associated with preterm birth are potentially preventable". Our team reanalyzed the results and found in the regression model that premature rupture of membranes was the only variable associated with preterm birth. This variable is not 100% preventable, so the results found are different from the authors' conclusions.

El parto pretérmino es un problema a nivel mundial que tiene un alto impacto económico y de morbimortalidad en los niños. Por lo tanto, la literatura se ha centrado en encontrar factores modificables asociados a esta entidad, como el estudio de "Factores de riesgo asociados a parto pretérmino en un hospital de segundo nivel de atención", el cual tiene como conclusión que "El 100% de los factores asociados a parto pretérmino son potencialmente prevenibles". Nuestro equipo volvió a analizar los resultados y encontró en el modelo de regresión que la ruptura prematura de membranas fue la única variable asociada a parto pretérmino. Esta variable no es 100% prevenible, por lo que los resultados encontrados son diferentes a las conclusiones de los autores.

Combined Nutrition in Very-Low-Birth-Weight Preterm Infants in the Neonatal Intensive Care Unit.

Background Adequate nutritional support is crucial for achieving optimal growth and development in very-low-birth-weight (VLBW) preterm infants. This study evaluated the efficacy of combined nutrition (CN) (parenteral plus enteral nutrition (EN)) as an alternative nutrition protocol for VLBW infants in the neonatal intensive care unit (NICU). Methods This retrospective cohort study collected clinical and growth data from the medical records of VLBW infants weighing between 1,000 and 1,500 grams in the NICU of the Hospital of Obstetrics and Gynecology "Dr. Víctor Manuel Espinosa de los Reyes Sánchez" of the Centro Médico Nacional "La Raza" Instituto Mexicano del Seguro Social, Mexico. Parenteral nutrition (PN) alone or CN (PN plus EN) was used for nutritional management. Statistical tests, such as Student's t-test, Mann-Whitney U test, and chi-square test as appropriate, were used to compare the clinical characteristics and growth data of the two groups, and relative risk was calculated to determine the probability of comorbidities according to feeding type. Statistical significance was set at p<0.05. Results The study included 90 VLBW infants, with 27 receiving PN alone and 63 receiving CN. No statistically significant differences were found concerning sex, age, or Apgar score. The CN group showed better weight gain with statistically significant differences at 28 days (p=0.002), with no increase in the relative risk of necrotizing enterocolitis (NEC) or other complications. Conclusions The CN protocol met the caloric and nutritional needs, without increasing morbidity and mortality. The protocol had a positive impact on weight gain and a shorter NICU stay and should be considered as a nutritional alternative for VLBW infants.

Risk Assessment of Dyslipidemias, Hyperglycemia, Hyperuricemia, and Hypertension Utilizing Self-Reported Body Silhouettes.

Objective: Self-reported body silhouette is an anthropometric instrument that has been utilized as a screening tool for underweight, overweight, obesity, and other abnormal anthropometric variables. Herein, we analyzed the risk associated with the self-reported body silhouette in the scope of dyslipidemias, hyperglycemia, hyperuricemia, and hypertension. Methods: Adult participants of the Health Workers Cohort Study enrolled between March 2004 and April 2006 were included. Then, risk analysis was performed considering dyslipidemias as serum triglycerides, high total cholesterol, high LDL-C, low HDL-C, hyperglycemia, hyperuricemia, and hypertension. Results: A total of 2,297 males and 5,003 females were analyzed. The median ages of the studied population was 39 (30-49) and 41 (31-50) years for males and females, respectively. Overall, there is a stepwise increase in the risk of presenting dyslipidemias, hyperglycemia, hyperuricemia, and hypertension as the self-reported body silhouette number increases, this tendency was observed in both males and females. Conclusion: Self-reported body silhouette is a useful risk assessment tool for dyslipidemias, hyperglycemia, hyperuricemia, and hypertension in Mexican adults. Applications of questioners containing this silhouette might be considered a valuable public health instrument due to their low cost, relative simplicity, and absence of specialized equipment, training, or respondent knowledge.

Cisplatin-induced nephrotoxicity in childhood cancer: comparison between two countries.

BACKGROUND: Various definitions used to describe cisplatin nephrotoxicity potentially lead to differences in determination of risk factors. This study evaluated incidence of kidney injury according to commonly used and alternative definitions in two cohorts of children who received cisplatin. METHODS: This retrospective cohort study included children from Vancouver, Canada (one center), and Mexico City, Mexico (two centers), treated with cisplatin for a variety of solid tumors. Serum creatinine-based definitions (KDIGO and Pediatric RIFLE (pRIFLE)), electrolyte abnormalities consisted of hypokalemia, hypophosphatemia and hypomagnesemia (based on NCI-CTCAE v5), and an alternative definition (Alt-AKI) were used to describe nephrotoxicity. Incidence with different definitions, definitional overlap, and inter-definition reliability was analyzed. RESULTS: In total, 173 children (100 from Vancouver, 73 from Mexico) were included. In the combined cohort, Alt-AKI criteria detected more patients with cisplatin nephrotoxicity compared to pRIFLE and KDIGO criteria (82.7 vs. 63.6 vs. 44.5%, respectively). Nephrotoxicity and all electrolyte abnormalities were significantly more common in Vancouver cohort than in Mexico City cohort except when using KDIGO definition. The most common electrolyte abnormalities were hypomagnesemia (88.9%, Vancouver) and hypophosphatemia (24.2%, Mexico City). The KDIGO definition provided highest overlap of cases in Vancouver (100%), Mexico (98.6%), and the combined cohort (99.4%). Moderate overall agreement was found among Alt-AKI, KDIGO, and pRIFLE definitions (κ = 0.18, 95% CI 0.1-0.27) in which KDIGO and pRIFLE showed moderate agreement (κ = 0.48, 95% CI 0.36-0.60). CONCLUSIONS: Compared to pRIFLE and KDIGO criteria, Alt-AKI criteria detected more patients with cisplatin nephrotoxicity. pRIFLE is more sensitive to detect not only actual kidney injury but also patients at risk of cisplatin nephrotoxicity, while KDIGO seems more useful to detect clinically significant kidney injury. A higher resolution version of the Graphical abstract is available as Supplementary information.

Risk factors associated with SARS-CoV-2 pneumonia in the pediatric population.

INTRODUCCIÓN: Hasta ahora existen pocos estudios sobre las características clínicas de la población pediátrica con neumonía por COVID-19. El objetivo de este estudio fue analizar los datos que se asocian con el desarrollo de neumonía en niños y adolescentes con infección por SARS-CoV-2 en México. MÉTODOS: Se llevó a cabo un análisis secundario de la base de datos de la Dirección General de Epidemiología del Gobierno Mexicano. Se incluyeron menores de 19 años con infección por SARS-CoV-2 confirmada mediante la prueba de retrotranscripción acoplada a la reacción en cadena de la polimerasa (RT-PCR). La variable dependiente fue el diagnóstico de neumonía. Se calcularon las razones de momios (RM) y los intervalos de confianza del 95% (IC95%). Se realizaron modelos de regresión logística múltiple para ajustar los factores asociados a neumonía. RESULTADOS: Se incluyeron 1443 niños con diagnóstico de COVID-19. La mediana de edad de los participantes fue de 12 años (rango intercuartilar 25-75: 5-16). La neumonía se presentó en 141 niños (9.8%). Los principales factores de riesgo fueron edad < 3 años (RM: 3.5; IC95%: 2.45-5.03), diabetes u obesidad (RM: 12.6; IC95%: 4.62-34.91) e inmunocompromiso (RM: 7.03; IC95%: 3.97-13.61). CONCLUSIONES: Los niños con COVID-19 menores de 3 años y con comorbilidad, especialmente diabetes u obesidad, y los inmunocomprometidos presentan mayor riesgo de desarrollar neumonía. BACKGROUND: Currently, there are a few studies on the clinical characteristics of the pediatric population with COVID-19 and pneumonia. This study aimed to analyze data associated with the development of pneumonia in children and adolescents with SARS-CoV-2 infection throughout Mexico. METHODS: We conducted a secondary analysis of the database of the Dirección General de Epidemiología of the Mexican Government. We included children under the age of 19 who were confirmed with SARS-CoV-2 infection by reverse transcription-polymerase chain reaction (RT-PCR) test. The dependent variable was the diagnosis of pneumonia. Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated. Multiple logistic regression models were performed to adjust factors associated with pneumonia. RESULTS: A total of 1443 children with a COVID-19 diagnosis were included. The median age of the participants was 12 years (interquartile range 25, 75: 5, 16). Pneumonia occurred in 141 children (9.8%). The main risk factors were age < 3 years (OR, 3.5; 95%CI, 2.45-5.03); diabetes or obesity (OR, 12.6; 95%CI, 4.62-34.91); and immunocompromise (OR, 7.03; 95%CI, 3.97-13.61). CONCLUSIONS: Children < 3 years with COVID-19 and comorbidities, especially diabetes or obesity, and immunocompromised patients have a higher risk of developing pneumonia.

Risk factors associated with SARS-CoV-2 pneumonia in the pediatric population / Factores de riesgo asociados con neumonía por SARS-CoV-2 en población pediátrica

Abstract Background: Currently, there are a few studies on the clinical characteristics of the pediatric population with COVID-19 and pneumonia. This study aimed to analyze data associated with the development of pneumonia in children and adolescents with SARS-CoV-2 infection throughout Mexico. Methods: We conducted a secondary analysis of the database of the Dirección General de Epidemiología of the Mexican Government. We included children under the age of 19 who were confirmed with SARS-CoV-2 infection by reverse transcription-polymerase chain reaction (RT-PCR) test. The dependent variable was the diagnosis of pneumonia. Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated. Multiple logistic regression models were performed to adjust factors associated with pneumonia. Results: A total of 1443 children with a COVID-19 diagnosis were included. The median age of the participants was 12 years (interquartile range 25, 75: 5, 16). Pneumonia occurred in 141 children (9.8%). The main risk factors were age < 3 years (OR, 3.5; 95%CI, 2.45-5.03); diabetes or obesity (OR, 12.6; 95%CI, 4.62-34.91); and immunocompromise (OR, 7.03; 95%CI, 3.97-13.61). Conclusions: Children < 3 years with COVID-19 and comorbidities, especially diabetes or obesity, and immunocompromised patients have a higher risk of developing pneumonia.

Resumen Introducción: Hasta ahora existen pocos estudios sobre las características clínicas de la población pediátrica con neumonía por COVID-19. El objetivo de este estudio fue analizar los datos que se asocian con el desarrollo de neumonía en niños y adolescentes con infección por SARS-CoV-2 en México. Métodos: Se llevó a cabo un análisis secundario de la base de datos de la Dirección General de Epidemiología del Gobierno Mexicano. Se incluyeron menores de 19 años con infección por SARS-CoV-2 confirmada mediante la prueba de retrotranscripción acoplada a la reacción en cadena de la polimerasa (RT-PCR). La variable dependiente fue el diagnóstico de neumonía. Se calcularon las razones de momios (RM) y los intervalos de confianza del 95% (IC95%). Se realizaron modelos de regresión logística múltiple para ajustar los factores asociados a neumonía. Resultados: Se incluyeron 1443 niños con diagnóstico de COVID-19. La mediana de edad de los participantes fue de 12 años (rango intercuartilar 25-75: 5-16). La neumonía se presentó en 141 niños (9.8%). Los principales factores de riesgo fueron edad < 3 años (RM: 3.5; IC95%: 2.45-5.03), diabetes u obesidad (RM: 12.6; IC95%: 4.62-34.91) e inmunocompromiso (RM: 7.03; IC95%: 3.97-13.61). Conclusiones: Los niños con COVID-19 menores de 3 años y con comorbilidad, especialmente diabetes u obesidad, y los inmunocomprometidos presentan mayor riesgo de desarrollar neumonía.