Design, construction, and validation of obstetric risk classification systems to predict intensive care unit admission.

INTRODUCTION: To develop and validate a support tool for healthcare providers, enabling them to make precise and critical decisions regarding intensive care unit (ICU) admissions for high-risk pregnant women, thus enhancing maternal outcomes. METHODS: This retrospective study involves secondary data analysis of information gathered from 9550 pregnant women, who had severe maternal morbidity (any unexpected complication during labor and delivery that leads to substantial short-term or long-term health issues for the mother), collected between 2009 and 2010 from the Brazilian Network for Surveillance of Severe Maternal Morbidity, encompassing 27 obstetric reference centers in Brazil. Machine-learning models, including decision trees, Random Forest, Gradient Boosting Machine (GBM), and Extreme Gradient Boosting (XGBoost), were employed to create a risk prediction tool for ICU admission. Subsequently, sensitivity analysis was conducted to compare the accuracy, predictive power, sensitivity, and specificity of these models, with differences analyzed using the Wilcoxon test. RESULTS: The XGBoost algorithm demonstrated superior efficiency, achieving an accuracy rate of 85%, sensitivity of 42%, specificity of 97%, and an area under the receiver operating characteristic curve of 86.7%. Notably, the estimated prevalence of ICU utilization by the model (11.6%) differed from the prevalence of ICU use from the study (21.52%). CONCLUSION: The developed risk engine yielded positive results, emphasizing the need to optimize intensive care bed utilization and objectively identify high-risk pregnant women requiring these services. This approach promises to enhance the effective and efficient management of pregnant women, particularly in resource-constrained regions worldwide. By streamlining ICU admissions for high-risk cases, healthcare providers can better allocate critical resources, ultimately contributing to improved maternal health outcomes.

Prospective validation of a preoperative scoring system for difficult laparoscopy cholecystectomy.

Difficult laparoscopic cholecystectomy (LC) is defined by its surgical outcomes, including operative time, conversion to open surgery, bile duct and/or vascular injury. Difficult LC can be graded based on intraoperative findings. The main objective of this study is to apply and validate the reliability of their proposed risk score to predict the operative difficulty of an LC, based on their own validated intraoperative scale. Single-center prospective cohort study from 01/2020-12-2023. 367 patients > 18 years who underwent LC were included. The preoperative risk scale and intraoperative grading system were registered. Surgical outcomes were determined. Predictive accuracy was evaluated by the Receiver Operator Characteristic curve, sensitivity, specificity, positive, and negative predictive values, and Youden's Index (J). Patients' mean age was 44.1 ± 15.3 years. According to the risk score, 39.5% LC were "low" risk difficulty, 49.3% were "medium" risk, and 11.2% were "high" risk difficult LC. Based on the intraoperative grading system, 31.9% were difficult LC (Nassar grades 3-4) and 68.1% were easy LC (Nassar grades 1-2). There was a statistically significant correlation (0.428, p < 0.05) between the preoperative risk score and the intraoperative grading system. The AUC for the preoperative risk score scale and intraoperative difficult LC was 0.735 (95% CI 0.687-0.779) (J: 0.34). A preoperative risk score > 1.5 had an 83.7% sensitivity and a 50.8% specificity for intraoperative difficult LC. A predictive preoperative score for difficult LC and a routine collection of the intraoperative difficulty should be implemented to improve surgical outcomes and surgical planning.

Reducing delivery insurance costs through risk score model for food delivery company.

In this paper, we propose a novel pricing model for delivery insurance in a food delivery company in Latin America, with the aim of reducing the high costs associated with the premium paid to the insurer. To achieve this goal, a thorough analysis was conducted to estimate the probability of losses based on delivery routes, transportation modes, and delivery drivers' profiles. A large amount of data was collected and used as a database, and various statistical models and machine learning techniques were employed to construct a comprehensive risk profile and perform risk classification. Based on the risk classification and the estimated probability associated with it, a new pricing model for delivery insurance was developed using advanced mathematical algorithms and machine learning techniques. This new pricing model took into account the pattern of loss occurrence and high and low-risk behaviors, resulting in a significant reduction of insurance costs for both the contracting company and the insurer. The proposed pricing model also allowed for greater flexibility in insurance contracting, making it more accessible and appealing to delivery drivers. The use of estimated loss probabilities and a risk score for the pricing of delivery insurance proved to be a highly effective and efficient alternative for reducing the high costs associated with insurance, while also improving the profitability and competitiveness of the food delivery company in Latin America.

Adição da Troponina Ultrassensível à Avaliação de Risco Perioperatório Melhora a Capacidade Preditiva de Morte em Pacientes Submetidos à Cirurgia Não Cardíaca / Addition of High-Sensitivity Troponin to Perioperative Risk Assessment Improves the Predictive Ability of Death in Non-Cardiac Surgery Patients

Resumo Fundamento A estratificação ode risco é uma importante etapa na avaliação perioperatória. No entanto, os principais escores de risco não incorporam biomarcadores em seus conjuntos de variáveis. Objetivo Avaliar o poder incremental da troponina à estratificação de risco tradicional. Métodos Um total de 2230 pacientes admitidos na unidade de terapia intensiva após cirurgia não cardíaca foram classificados de acordo com três tipos de risco: Risco Cardiovascular (RCV), Índice de Risco Cardíaco Revisado (IRCR), e Risco Inerente da Cirurgia (RIC). O principal desfecho foi mortalidade por todas as causas. A regressão de Cox foi usada, assim como a estatística C antes e após a adição de troponina ultrassensível (pelo menos uma medida até três dias após a cirurgia). Finalmente, o índice de reclassificação líquida e a melhoria de discriminação integrada foram usadas para avaliar o poder incremental da troponina para a estratificação de risco. O nível de significância usado foi de 0,05. Resultados A idade média dos pacientes foi 63,8 anos e 55,6% eram do sexo feminino. A prevalência de lesão miocárdica após cirurgia não cardíaca (MINS) foi 9,4%. Pacientes com um RCV elevado apresentaram uma maior ocorrência de MINS (40,1% x 24,8%, p<0,001), bem como pacientes com alto RIC (21,3 x 13,9%, p=0,004) e aqueles com IRCR≥3 (3,0 x 0,7%, p=0,009). Pacientes sem MINS, independentemente do risco avaliado, apresentaram taxa de mortalidade similar. A adição de troponina à avaliação de risco melhorou a capacidade preditiva de mortalidade em 30 dias e de mortalidade em um ano em todas as avaliações de risco. Conclusão A prevalência de MINS é mais alta na população de alto risco. No entanto, sua prevalência na população de risco mais baixo não é desprezível e causa um maior risco de morte. A adição da troponina ultrassensível melhorou a capacidade preditiva da avaliação de risco em todos os grupos.

Abstract Background Risk stratification is an important step in perioperative evaluation. However, the main risk scores do not incorporate biomarkers in their set of variables. Objective Evaluate the incremental power of troponin to the usual risk stratification Methods A total of 2,230 patients admitted to the intensive care unit after non-cardiac surgery were classified according to three types of risk: cardiovascular risk (CVR), Revised Cardiac Risk Index (RCRI); and inherent risk of surgery (IRS). The main outcome was all-cause mortality. Cox regression was used as well as c-statistics before and after addition of high-sensitivity troponin (at least one measurement up to three days after surgery). Finally, net reclassification index and integrated discrimination improvement were used to assess the incremental power of troponin for risk stratification. Significance level was set at 0.05. Results Mean age of patients was 63.8 years and 55.6% were women. The prevalence of myocardial injury after non-cardiac surgery (MINS) was 9.4%. High CVR-patients had a higher occurrence of MINS (40.1 x 24.8%, p<0.001), as well as high IRS-patients (21.3 x 13.9%, p=0.004) and those with a RCRI≥3 (3.0 x 0.7%, p=0.009). Patients without MINS, regardless of the assessed risk, had similar mortality rate. The addition of troponin to the risk assessment improved the predictive ability of death at 30 days and at 1 year in all risk assessments. Conclusion The prevalence of MINS is higher in the high-risk population. However, its prevalence in lower-risk population is not negligible and causes a higher risk of death. The addition of high-sensitivity troponin increased the predictive ability of risk assessment in all groups.

A decision support system to recommend appropriate therapy protocol for AML patients.

Introduction: Acute Myeloid Leukemia (AML) is one of the most aggressive hematological neoplasms, emphasizing the critical need for early detection and strategic treatment planning. The association between prompt intervention and enhanced patient survival rates underscores the pivotal role of therapy decisions. To determine the treatment protocol, specialists heavily rely on prognostic predictions that consider the response to treatment and clinical outcomes. The existing risk classification system categorizes patients into favorable, intermediate, and adverse groups, forming the basis for personalized therapeutic choices. However, accurately assessing the intermediate-risk group poses significant challenges, potentially resulting in treatment delays and deterioration of patient conditions. Methods: This study introduces a decision support system leveraging cutting-edge machine learning techniques to address these issues. The system automatically recommends tailored oncology therapy protocols based on outcome predictions. Results: The proposed approach achieved a high performance close to 0.9 in F1-Score and AUC. The model generated with gene expression data exhibited superior performance. Discussion: Our system can effectively support specialists in making well-informed decisions regarding the most suitable and safe therapy for individual patients. The proposed decision support system has the potential to not only streamline treatment initiation but also contribute to prolonged survival and improved quality of life for individuals diagnosed with AML. This marks a significant stride toward optimizing therapeutic interventions and patient outcomes.

Establishment of a 7-gene expression panel to improve the prognosis classification of gastric cancer patients.

Gastric cancer (GC) ranks fifth in incidence and fourth in mortality worldwide. The high death rate in patients with GC requires new biomarkers for improving survival estimation. In this study, we performed a transcriptome-based analysis of five publicly available cohorts to identify genes consistently associated with prognosis in GC. Based on the ROC curve, patients were categorized into high and low-expression groups for each gene using the best cutoff point. Genes associated with survival (AUC > 0.5; univariate and multivariate Cox regressions, p < 0.05) were used to model gene expression-based scores by weighted sum using the pooled Cox ß regression coefficients. Cox regression (p < 0.05), AUC > 0.5, sensitivity > 0.5, and specificity > 0.5 were considered to identify the best scores. Gene set enrichment analysis (KEGG, REACTOME, and Gene Ontology databases), as well as microenvironment composition and stromal cell signatures prediction (CIBERSORT, EPIC, xCell, MCP-counter, and quanTIseq web tools) were performed. We found 11 genes related to GC survival in the five independent cohorts. Then, we modeled scores by calculating all possible combinations between these genes. Among the 2,047 scores, we identified a panel based on the expression of seven genes. It was named GES7 and is composed of CCDC91, DYNC1I1, FAM83D, LBH, SLITRK5, WTIP, and NAP1L3 genes. GES7 features were validated in two independent external cohorts. Next, GES7 was found to recategorize patients from AJCC TNM stages into a best-fitted prognostic group. The GES7 was associated with activation of the TGF-ß pathway and repression of anticancer immune cells. Finally, we compared the GES7 with 30 previous proposed scores, finding that GES7 is one of the most robust scores. As a result, the GES7 is a reliable gene-expression-based signature to improve the prognosis estimation in GC.

Análise das complicações clínico-obstétricas em gestantes adolescentes segundo a Classificação de Robson / Analyzing clinical obstetric complications in pregnant adolescents by the Robson / Classification Análisis de las complicaciones clínico-obstétricas en adolescentes embarazadas según la Clasificación de Robson

Objetivo: analisar as complicações obstétricas de gestantes adolescentes por meio da Classificação de Robson. Método: trata-se de uma pesquisa quantitativa documental. Foram pesquisados 150 prontuários de gestantes adolescentes de alto risco. O estudo foi de setembro a novembro/2019 e iniciou após a aprovação do Comitê de ética em Pesquisa da Universidade Federal de Alagoas. Resultados: as taxas de cesáreas do grupo 1 foram o dobro do recomendado (18,92%), pela Classificação de Robson. No grupo 2, houve 100% de cesárea, enquanto recomendação é de 20 a 35%. No grupo 4 observou-se 100% de parto vaginal, enquanto os grupos 5, 8 e 10 excederam o número de cesáreas em cerca de 15,40 a 20%. Conclusão: evidenciou-se, por meio da Classificação de Robson, que o tipo de parto das gestantes adolescentes que foram afetadas por uma complicação clínico-obstétrica foi o parto cesáreo, com aumento nos grupos de gestante 1, 2, 5, 8 e 10.

Objective: to analyze obstetric complications in pregnant adolescents using the Robson Classification. Method: in this quantitative study, 150 medical records of high-risk adolescent pregnant women were searched between September and November 2019, after approval by the research ethics committee of Alagoas Federal University. Results: by the Robson Classification, cesarean section rates in group 1 were twice as high as recommended (18.92%). Group 2 returned 100% cesarean section, while the recommendation is 20 to 35%; group 4 showed 100% vaginal deliveries; and, in groups 5, 8 and 10, these exceeded the number of cesarean sections by about 15.40 to 20%. Conclusion: using the Robson Classification, it was shown that pregnant adolescents affected by a clinical obstetric complication were delivered by cesarean sections, which increased in groups 1, 2, 5, 8 and 10.

Objetivo: analizar las complicaciones obstétricas en adolescentes embarazadas mediante la Clasificación de Robson. Método: se trata de una investigación cuantitativa documental. Se investigaron 150 historias clínicas de adolescentes embarazadas de alto riesgo. El estudio fue de septiembre a noviembre/2019 y se inició después de la aprobación del Comité de Ética en Investigación de la Universidad Federal de Alagoas. Resultados: Las tasas de cesáreas en el grupo 1 fueron el doble de lo recomendado (18,92%) según la clasificación. En el grupo 2, hubo 100% de cesáreas, mientras que la recomendación es del 20 al 35%. En el grupo 4, el 100% tuvo parto vaginal, mientras que los grupos 5, 8 y 10 superaron el número de cesáreas en aproximadamente del 15,40 al 20%. Conclusión: queda claro, a través de la Clasificación de Robson, que el tipo de parto de las adolescentes embarazadas que se vio afectado por una complicación clínico-obstétrica fue el cesáreo, con incremento en los grupos de embarazadas 1, 2, 5, 8 y 10.

The BRAFV600E mutation analysis and risk stratification in papillary thyroid carcinoma.

OBJECTIVE: Although the prognostic role of BRAFV600E mutation in papillary thyroid carcinoma (PTC) is controversial, the American Thyroid Association (ATA) includes the mutational status in their risk stratification system. To evaluate the impact of the BRAFV600E mutation status on PTC risk stratification. METHODS: PTC patients attending a university-based hospital who had the analysis of the BRAFV600E mutation were included. Persistent disease was defined as the presence of biochemical or structural disease. The performance of the ATA risk stratification system on predicting persistent disease with or without the BRAFV600E mutation status information was evaluated. RESULTS: Of the 134 patients evaluated, 44 (32.8%) carried BRAFV600E mutation. The median tumor size was 1.7 cm (P25-75 1.0-3.0), 64 (47.8%) patients had lymph node, and 11 (8.2%) distant metastases. According to the ATA risk stratification system, patients were classified as low, intermediate, and high risk in 55 (41%), 59 (44%), and 20 (14%) patients, respectively. The data on BRAFV600E mutation reclassified 12 (8.9%) patients from low to intermediate risk. After a median follow-up of 8.5 years, the prevalence of persistent disease was similar in patients with and without BRAFV600E mutation (P = 0.42). Multivariate analysis failed to demonstrate an association between the BRAFV600E mutation and persistent disease status (RR 0.96; 95%CI 0.47-1.94). Notably, none of the patients reclassified from low to intermediate risk showed persistent disease on follow-up. CONCLUSION: Inclusion of BRAFV600E mutational status has a limited impact on risk stratification and does not add to the prediction of outcomes in PTC patients.

The BRAFV600E mutation analysis and risk stratification in papillary thyroid carcinoma

ABSTRACT Objective: Although the prognostic role of BRAFV600E mutation in papillary thyroid carcinoma (PTC) is controversial, the American Thyroid Association (ATA) includes the mutational status in their risk stratification system. To evaluate the impact of the BRAFV600E mutation status on PTC risk stratification. Subjects and methods: PTC patients attending a university-based hospital who had the analysis of the BRAFV600E mutation were included. Persistent disease was defined as the presence of biochemical or structural disease. The performance of the ATA risk stratification system on predicting persistent disease with or without the BRAFV600E mutation status information was evaluated. Results: Of the 134 patients evaluated, 44 (32.8%) carried BRAFV600E mutation. The median tumor size was 1.7 cm (P25-75 1.0-3.0), 64 (47.8%) patients had lymph node, and 11 (8.2%) distant metastases. According to the ATA risk stratification system, patients were classified as low, intermediate, and high risk in 55 (41%), 59 (44%), and 20 (14%) patients, respectively. The data on BRAFV600E mutation reclassified 12 (8.9%) patients from low to intermediate risk. After a median follow-up of 8.5 years, the prevalence of persistent disease was similar in patients with and without BRAFV600E mutation (P = 0.42). Multivariate analysis failed to demonstrate an association between the BRAFV600E mutation and persistent disease status (RR 0.96; 95%CI 0.47-1.94). Notably, none of the patients reclassified from low to intermediate risk showed persistent disease on follow-up. Conclusion: Inclusion of BRAFV600E mutational status has a limited impact on risk stratification and does not add to the prediction of outcomes in PTC patients.

Revisiting area risk classification of visceral leishmaniasis in Brazil.

BACKGROUND: Visceral leishmaniasis (VL) is a neglected tropical disease of public health relevance in Brazil. To prioritize disease control measures, the Secretaria de Vigilância em Saúde of Brazil's Ministry of Health (SVS/MH) uses retrospective human case counts from VL surveillance data to inform a municipality-based risk classification. In this study, we compared the underlying VL risk, using a spatiotemporal explicit Bayesian hierarchical model (BHM), with the risk classification currently in use by the Brazil's Ministry of Health. We aim to assess how well the current risk classes capture the underlying VL risk as modelled by the BHM. METHODS: Annual counts of human VL cases and the population at risk for all Brazil's 5564 municipalities between 2004 and 2014 were used to fit a relative risk BHM. We then computed the predicted counts and exceedence risk for each municipality and classified them into four categories to allow comparison with the four risk categories by the SVS/MH. RESULTS: Municipalities identified as high-risk by the model partially agreed with the current risk classification by the SVS/MH. Our results suggest that counts of VL cases may suffice as general indicators of the underlying risk, but can underestimate risks, especially in areas with intense transmission. CONCLUSION: According to our BHM the SVS/MH risk classification underestimated the risk in several municipalities with moderate to intense VL transmission. Newly identified high-risk areas should be further evaluated to identify potential risk factors and assess the needs for additional surveillance and mitigation efforts.

Evaluation of drug prescriptions for pregnant women in the Legal Amazon Region / Avaliação de prescrições medicamentosas para gestantes da Amazônia Legal

Abstract Objectives: to evaluate the drug prescriptions for pregnant women in the Legal Amazon during prenatal care. Methods: this is a pharmacoepidemiological, descriptive, retrospective and cross-sectional study. Medical records included sociodemographic variables, prenatal care, most frequent pharmacological classes prescribed, risk classification of drugs and possible drug-drug interactions among pregnant women. Results: a total of 159 records from pregnant women, enrolled in the Unified Health System were used. Most pregnant women began prenatal consultations in the first trimester of pregnancy (53.3%) whereas most of the drugs were prescribed in the second gestational trimester (55.5%). The most used pharmacological classes, classified according to the National List of Essential Drugs were: antianemic preparations (52.9%), vitamins (12.5%) and analgesic (10.6%). According to the risk classification, the highest prevalence of prescribed drugs belongs to category A (46.8%), followed by category C (28.9%), category B (20.0%) and category D (4.3%). Eight possible drug-drug interactions were found, being considered with mild severity, and six classified with moderate risk. Conclusions: the results demonstrate a lack of information regarding prescription drugs for pregnant women and this may endanger maternal and fetal health. It is essential that medical records be an effective therapeutic tool, which should be read, analyzed and reviewed in order to ensure effective and safe medical treatment.

Resumo Objetivos: avaliar a prescrição de medicamentos para gestantes da Amazônia Legal, durante o pré-natal. Métodos: trata-se de um estudo farmacoepidemiológico, descritivo, retrospectivo e transversal. Através de prontuários médicos foram avaliados variáveis sociodemográficas, assistência pré-natal, classes farmacológicas mais prescritas, classificações de risco e possíveis interações medicamentosas nas gestantes. Resultados: foram utilizados 159 prontuários de gestantes usuárias do Sistema Único de Saúde. A maioria das grávidas iniciaram as consultas do pré-natal no primeiro trimestre gestacional (53,3%) e a maior parte dos medicamentos prescritos foram no segundo trimestre gestacional (55,5%). As classes mais utilizadas conforme a Relação Nacional de Medicamentos Essenciais foram: preparações antianêmicas (52,9%), vitaminas (12,5%) e analgésico (10,6%). De acordo com a classificação de risco, a prevalência maior dos medicamentos prescritos pertence à categoria A de risco (46,8%), seguido da categoria C (28,9%), categoria B (20,0%) e categoria D (4,3%). Foram encontradas oito possíveis interações medicamentosas, sendo duas consideradas de risco leve e seis de risco moderado. Conclusões: os resultados demonstram falhas na prescrição de medicamentos para gestantes o que pode colocar em risco a saúde materna e fetal. É fundamental que o prontuário médico seja uma ferramenta terapêutica efetiva, o qual deve ser lido, analisado e revisado a fim de garantir um tratamento medicamentoso eficaz e seguro.

Classificação de risco em unidade de pronto atendimento: discursos dos enfermeiros / Risk classification in an emergency care unit: the nurses' discourse / Clasificación de riesgo en unidad de urgencias: discursos de los enfermeros

Objetivo: conhecer a percepção dos enfermeiros de uma unidade de pronto atendimento acerca da classificação de risco. Método: estudo qualitativo, descritivo, realizado com nove enfermeiros de uma unidade de pronto atendimento de Florianópolis, por meio de entrevista semiestruturada, no período de abril a junho de 2014. Para a organização e análise dos dados, utilizou-se a técnica do Discurso do Sujeito Coletivo. Projeto aprovado por Comitê de Ética em Pesquisa, protocolo nº 17041613.8.0000.0121. Resultados: emergiram dois discursos com as ideias centrais: a classificação de risco além de priorizar o atendimento aos pacientes mais graves dá mais segurança ao profissional; e, cada enfermeiro avalia, classifica e registra de um jeito. Conclusão: apesar de os enfermeiros considerarem a importância da classificação de risco na unidade de pronto atendimento, encontram dificuldades quanto à unicidade de conduta na sua implementação e registro, sinalizando a necessidade de ações de educação permanente para uma melhor organização no atendimento.

Objective: to examine nurses' perceptions of risk classification in an emergency unit. Method: in this qualitative, descriptive study, nine nurses at an emergency unit in Florianópolis underwent semi-structured interviews between April and June 2014. Collective Subject Discourse was used as an organizational and data analysis technique. The project was approved by the Research Ethics Committee (Protocol No. 17041613.8.0000.0121). Results: two discourses emerged with the core ideas: risk assessment, in addition to prioritizing critical patient care, gives health personnel more security; and each nurse assesses, classifies and records in a particular way. Conclusion: although nurses consider risk classification important in the emergency unit, they find difficulty as regards standard conduct in implementing it and in recording, which signals a need for continuous education actions to improve care organization.

Objetivo: conocer el punto de vista de los enfermeros de una unidad de urgencias acerca de la clasificación de riesgo. Método: es un estudio cualitativo, descriptivo, realizado junto a nueve enfermeros de una Unidad de Urgencias de Florianópolis, por medio de una entrevista semiestructurada, entre abril y junio del 2014. Se utilizó, como técnica de organización y análisis de datos, el Discurso del Sujeto Colectivo. Proyecto aprobado por el Comité de Ética en Investigación, Protocolo nº 17041613.8.0000.0121. Resultados: surgieron dos discursos cuyas ideas centrales son: la clasificación del riesgo, además de priorizar la atención de los pacientes más graves, le ofrece más seguridad al profesional; y cada enfermero evalúa, clasifica y registra de una manera diferente. Conclusión: aunque los enfermeros hayan considerado la importancia de la clasificación de riesgo en la unidad de urgencias, ellos encuentran dificultades en cuanto a la unicidad de conducta en su implementación y registro, señalando la necesidad de acciones de educación permanente para una mejor organización respecto a la atención al paciente.

Prospective validation of the ultrasound based TIRADS (Thyroid Imaging Reporting And Data System) classification: results in surgically resected thyroid nodules.

OBJECTIVE: To assess performance of TIRADS classification on a prospective surgical cohort, demonstrating its clinical usefulness. METHODS: Between June 2009 and October 2012, patients assessed with pre-operative ultrasound (US) were included in this IRB-approved study. Nodules were categorised according to our previously described TIRADS classification. Final pathological diagnosis was obtained from the thyroidectomy specimen. Sensitivity, specificity, positive/negative predictive values and likelihood ratios were calculated. RESULTS: The study included 210 patients with 502 nodules (average: 2.39 (±1.64) nodules/patient). Median size was 7 mm (3-60 mm). Malignancy was 0 % (0/116) in TIRADS 2, 1.79 % (1/56) in TIRADS 3, 76.13 % (185/243) in TIRADS 4 [subgroups: TIRADS 4A 5.88 % (1/17), TIRADS 4B 62.82 % (49/78), TIRADS 4C 91.22 % (135/148)], and 98.85 % (86/87) in TIRADS 5. With a cut-off point at TIRADS 4-5 to perform FNAB, we obtained: sensitivity 99.6 % (95 % CI: 98.9-100.0), specificity 74.35 % (95 % CI: 68.7-80.0), PPV 82.1 % (95 % CI: 78.0-86.3), NPV 99.4 % (95 % CI: 98.3-100.0), PLR 3.9 (95 % CI: 3.6-4.2) and an NLR 0.005 (95 % CI: 0.003-0.04) for malignancy. CONCLUSION: US-based TIRADS classification allows selection of nodules requiring FNAB and recognition of those with a low malignancy risk. KEY POINTS: • TIRADS classification allows accurate selection of thyroid nodules requiring biopsy (TIRADS 4-5). • The recognition of benign/possibly benign patterns can avoid unnecessary procedures. • This classification and its sonographic patterns are validated using surgical specimens.

Utility of 18F-FDG-PET/CT in patients suspected of paraneoplastic neurological syndrome: importance of risk classification.

PURPOSE: To assess the diagnostic impact of 18F-FDG-PET/CT in patients suspected of paraneoplastic neurological syndrome (PNS) based on our own pre-test risk classification (PRC). METHODS: A multicenter retrospective longitudinal study was conducted from 2006 to 2014. We designed a seven-point scoring system using the clinical syndrome characteristics [classical (CS) and non-classical syndromes (NCS)] and its location (central, peripheral, in the neuromuscular junction or combined), onconeural antibodies and tumor markers. Patients were classified as low (score 0-2), intermediate (3-4) and high (5-7) pre-test risk of PNS. FDG-PET/CT was classified as negative or positive. Final diagnosis according Graus' criteria (definite, possible or no PNS) was established. Relations between clinical and metabolic variables with the final diagnosis were studied. RESULTS: 73 patients were included, with a follow-up time of 33 months. Eleven (15 %) patients were finally diagnosed with neoplasm (8 invasive cancers). Ultimately, 13 (18 %) and 24 (33 %) subjects were diagnosed as definite or possible PNS. All the patients with final diagnosis of neoplasm had a CS (p = 0.005). PET/CT was helpful to diagnose 6/8 (75 %) invasive cancers. PET/CT findings were associated with the final diagnosis of neoplasm (p = 0.003) and the diagnosis of PNS attending to Graus' criteria (p = 0.019). PRC showed significant association with the final diagnosis of neoplasm and PET/CT results. A majority of patients (10/11) diagnosed of neoplasm had intermediate/high-risk. CONCLUSIONS: Our PRC seems to be a valid tool to select candidates for PET/CT imaging in this setting. PET/CT detected malignancy in a significant proportion of patients with invasive cancer.

Risk-Stratified Initial Salvage Therapy for Relapsed or Refractory Metastatic Germ Cell Tumors.

BACKGROUND: Salvage treatment with either conventional-dose chemotherapy (CDCT) or high-dose chemotherapy with autologous stem cell transplantation (HDCT) offers curative potential for patients with relapsed or refractory germ cell tumor (GCT). However, the optimal initial salvage strategy remains controversial, and the criteria for appropriate patient selection are not clear. METHODS: This was a retrospective analysis of the clinical outcomes for GCT patients receiving initial salvage therapy using a risk-stratified treatment approach. In general, patients with favorable-risk disease received CDCT with 4 cycles of paclitaxel, ifosfamide, and cisplatin, while patients with unfavorable-risk disease received HDCT per institutional protocol. The prognostic validity of the International Germ Cell Cancer Collaborative Group (IGCCCG) and the International Prognostic Factors Study Group (IPFSG) risk groups were evaluated in this context. RESULTS: Thirty-seven patients received initial salvage therapy. Twenty-four patients (65%) achieved a favorable response (including complete response to chemotherapy alone, complete response after post-chemotherapy surgical resection, or partial response with negative tumor markers). The favorable response rates for the CDCT and HDCT treatment groups were 69% and 62%, respectively. After a median follow-up of 31 months, the median survival for CDCT-treated patients has not been reached, and the median survival for the HDCT-treated group was 24 months. Both the International Germ Cell Cancer Collaborative Group and the International Prognostic Factors Study Group risk groups were significantly associated with progression-free survival (log-rank P = .009 and P = .039, respectively). CONCLUSIONS: Patients with favorable prognostic features may achieve durable remissions without requiring high-dose salvage chemotherapy. However, the criteria for optimal patient selection remain unclear, and these findings further support the need for a definitive randomized trial.

Early Detection for Dengue Using Local Indicator of Spatial Association (LISA) Analysis.

Dengue is a viral disease caused by a flavivirus that is transmitted by mosquitoes of the genus Aedes. There is currently no specific treatment or commercial vaccine for its control and prevention; therefore, mosquito population control is the only alternative for preventing the occurrence of dengue. For this reason, entomological surveillance is recommended by World Health Organization (WHO) to measure dengue risk in endemic areas; however, several works have shown that the current methodology (aedic indices) is not sufficient for predicting dengue. In this work, we modified indices proposed for epidemic periods. The raw value of the epidemiological wave could be useful for detecting risk in epidemic periods; however, risk can only be detected if analyses incorporate the maximum epidemiological wave. Risk classification was performed according to Local Indicators of Spatial Association (LISA) methodology. The modified indices were analyzed using several hypothetical scenarios to evaluate their sensitivity. We found that modified indices could detect spatial and differential risks in epidemic and endemic years, which makes them a useful tool for the early detection of a dengue outbreak. In conclusion, the modified indices could predict risk at the spatio-temporal level in endemic years and could be incorporated in surveillance activities in endemic places.

Perception of emergency nurses in using a chest pain assessment protocol / Percepción de enfermeros de emergencia en la utilización de un protocolo de evaluación del dolor torácico / Percepção dos enfermeiros de emergência na utilização de um protocolo para avaliação da dor torácica

A qualitative and descriptive study aimed at identifying the perception of nurses at the emergency service of a hospital in Southern Brazil on the use of a nursing protocol for classifying chest pain, implemented at a private hospital in the Brazilian Southeast. The protocol considers, among others, the characteristics of the chest pain, risk factors and flowcharts that lead to the nursing action of classifying the risk. Seven nurses participated in the study through semi-structured interview, between January and February 2014. For the data analysis, Content Analysis was used. The results reveal a consensus among nurses that the protocol prioritizes care; identifies risk factors for acute myocardial infarction more easily and identifies the type of pain. The lengthiness and time consumption were revealed as negative considerations. For the nurses, the protocol is applicable to the service as it supported their conduct.

Estudio cualitativo, descriptivo que objetivó identificar la percepción de enfermeros del Servicio de Emergencias de un hospital del Sur de Brasil sobre la utilización de un protocolo de Enfermería para clasificar el dolor torácico, implementado en un hospital privado de la región sureste de Brasil. Contempla, las características del dolor torácico, factores de riesgo y flujogramas, que conducen a la acción de enfermeros para clasificar el riesgo. Participaron del estudio siete enfermeros por medio de entrevista semi-estructurada, en enero-febrero del 2014. Para el análisis de datos se utilizó el análisis de contenido. Los resultados revelan consenso entre los enfermeros de que el protocolo prioriza el atendimiento, identifica más fácilmente los factores de riesgo para el Infarto Agudo de Miocardio e identifica el tipo de dolor. Como consideraciones negativas destacan ser extenso y demorado. Para los enfermeros el protocolo es aplicable al servicio, pues proporcionó respaldo en su conducta.

Estudo qualitativo, descritivo que objetivou identificar a percepção de enfermeiros do serviço de emergência de um hospital do Sul do Brasil sobre a utilização de um protocolo de enfermagem para classificar dor torácica, protocolo esse, já implementado em um hospital privado localizado na região sudeste brasileira. Contempla, entre outros, as características da dor torácica, fatores de risco e fluxogramas que conduzem a ação do enfermeiro ao classificá-la. Participaram do estudo sete enfermeiros por meio de entrevista semiestruturada, em janeiro e fevereiro de 2014. Para análise dos dados utilizou-se a análise de conteúdo. Os resultados apontam consenso entre os enfermeiros de que o protocolo prioriza o atendimento, identifica mais facilmente os fatores de risco para Infarto Agudo do Miocárdio e, também, o tipo de dor. Como considerações negativas apontam ser extenso e demorado. Para os enfermeiros, o protocolo é aplicável ao serviço, pois proporcionou respaldo em sua conduta.

O foco míope: apontamentos sobre o cuidado à crise em saúde mental em emergências de hospitais gerais / The myopic focus: notes about the crisis in mental health care emergencies in generalhospitals / El enfoque miope: notas sobre la crisis en el cuidado de emergencias de salud mental en los hospitales generales

O artigo discute a atenção à crise em saúde mental com base em uma pesquisa-intervenção em andamento que vem cartografando os modos de acolhimento operados em três emergências de hospitais gerais de Porto Alegre. Os processos de cuidado em relação à saúde mental aparecem tão plurais e individualizados quanto as estratégias de que estes trabalhadores lançam mão para dar conta das ansiedades que tais atendimentos mobilizam. Neste percurso de pesquisa no qual a dimensão de formação e intervenção não estão separadas, a proposta é de pôr em análise o acolhimento com classificação de risco junto ao tema da crise em saúde mental, na perspectiva da Política Nacional de Humanização. O medo ao desconhecido, oestigma associado à loucura e, fundamentalmente, a sensação de despreparo dos profissionais para escutar e resolver os problemas que surgem nos atendimentos emergenciais produz efeitos de invisibilidade sobre a dimensão da saúde mental presente em muitos desses atendimentos. Uma espécie de “foco míope” no trabalho aí desenvolvido emerge como efeito deste modo de trabalhar que, sendo tomado como analisador, pode apontar caminhos de resgate ao sentido, muitas vezes perdido, do acolhimento como diretriz e dispositivo de humanização da saúde.(AU)

This paper discusses the attention to the crisis in mental health mapping the reception modes operated in three general hospitals emergencies in Porto Alegre. The writing originates from an ongoing research intervention that began its incursion into the field from researchers' observations and interviews with studied service workers, in which the processes of care in relation to mental health are already showing themselves as plural and individualized as the strategies that these workers use to manage the anxieties that such care mobilizes. In this way of research in which the dimension of training and intervention are not separated, the proposal is to put on analysis the reception with risk classification with the theme of the crisis in mental health, on a perspective guided by the National Humanization Policy of Care. The fear of the unknown, the stigma associated with madness and, fundamentally, the fact that professionals feel unprepared to listen and solve problems that arise in emergency care,produces effects of invisibility about the dimension of mental health existent in many cases. A kind of "myopic focus" on these units work emerges as an effect of this way of workingwhich, being taken as analyzer, can point out ways to rescue the lost meaning, in many of these services, of the reception as a guideline and a device of humanization in health.(AU)

El artículo aborda la atención a la crisis en salud mental basado en una investigación-intervención en curso que viene cartografando los modos de acogida utilizados en tres emergencias de hospitales generales de Porto Alegre. Los processos de atención en salud mental se presentan tan plurales y individualizados como las estratégias de las cuales echan mano los trabajadores para hacer frente a las ansiedades movilizadas por estos atendimentos. En este proceso de investigación, en el cual la dimensión de la formación y de la intervención no estan separadas, la propuesta és de poner en análisis el Acogimiento con Clasificación de Riesgo y el tema de la crisis en salud mental, desde la perspectiva de la Política Nacional de Humanización. El miedo a lo desconocido, el estigma asociado con la locura y fundamentalmente el despreparo sentido por los profesionales para escuchar y resolver los problemas que surgen en la atención a las emergências produzen efectos de invisibilidad sobre la dimensión de la salud mental presente en muchos de estos atendimientos. Una especie de "enfoque miope" en el trabajo desarrollado surge como efecto de este modo de trabajar que, al ser tomado como analizador, puede señalar caminos hacia el rescate del sentido, muchas vezes perdido, del acogimento como diretriz y dispositivo de humanización de la salud.(AU)

Índices predictores de eventos adversos en el adulto inmunocompetente hospitalizado por neumonía neumocóccica adquirida en la comunidad / Severity scores for predicting clinically relevant outcomes for immunocompetent adult patients hospitalized with community-acquired pneumococcal pneumonia

Streptococcus pneumoniae is the main cause of community-acquired pneumonia (CAP) in adults. Objectives: To compare accuracy and discriminatory power of three validated rules for predicting clinically relevant adverse outcomes in patients hospitalized with community-acquired pneumococcal pneumonia. Measurements: We pros-pectively compared the pneumonia severity index (PSI), British Thoracic Society score (CURB-65) and severe CAP score (SCAP) in a cohort of 151 consecutive immunocompetent adult patients hospitalized with pneumo-coccal pneumonia. Major adverse outcomes were admission to ICU, need for mechanical ventilation, in-hospital complications and 30-day mortality. Mean hospital length of stay (LOS) was also evaluated. The predictive indexes were compared based on sensitivity, specificity, and area under the curve of the receiver operating characteristic. Results: The mean age of 151 immunocompetent adult patients hospitalized with pneumococcal pneumonia was 64 years (range, 16 to 92); 58 percent were male, 75 percent had comorbidities, 26 percent were admitted to the intensive care unit and 9 percent needed mechanical ventilation. The rate of all adverse outcomes and hospital LOS increased directly with increasing PSI, CURB-65 and SCAP scores. The three severity scores allowed us to predict the risk of in-hospital complications and 30-day mortality. The PSI score was more sensitive and the SCAP was more specific to predict in-hospital complications and the risk of death. However, the SCAP was more sensitive and specific in predicting the use of mechanical ventilation. Conclusion: The severity scores validated in the literature allow us to predict the risk of complications and death in adult patients hospitalized with pneumococcal pneumonia. Nevertheless, the clinical indexes differ in their sensitivity, specificity and discriminatory power to predict different adverse events.

Streptococcus pneumoniae es el principal agente causal de la neumonía adquirida en la comunidad. Objetivos: Examinar el poder discriminativo de tres índices pronósticos en la predicción de eventos adversos clínicamente relevantes en pacientes hospitalizados por neumonía neumocóccica adquirida en la comunidad. Métodos: Evaluamos el índice de gravedad de la neumonía (IGN), CURB-65 y el índice de neumonía grave adquirida en la comunidad (INGAC) en una cohorte de 151 adultos inmunocompetentes hospitalizados por neumonía neu-mocóccica. Los eventos adversos examinados fueron la admisión a UCI, necesidad de ventilación mecánica, complicaciones en el hospital y mortalidad a 30 días. Las reglas predictoras fueron comparadas en base a su sensibilidad, especificidad y área bajo la curva receptor operador. Resultados: Se evaluaron 151 pacientes (64 ± 18 años), 58 por ciento varones, 75 por ciento tenía co-morbilidad, 26 por ciento fueron admitidos a la UCI y 9 por ciento requirieron ventilación mecánica. La tasa de eventos adversos fue más elevada y la estadía en el hospital más prolongada en las categorías de alto riesgo de los tres índices predictores. Los tres índices permitieron, a su vez, predecir el riesgo de complicaciones y muerte en el seguimiento a 30 días. El IGN fue más sensible y el INGAC más específico en la pesquisa de complicaciones en el hospital y en predecir el riesgo de muerte. El INGAC fue más sensible y específico en predecir el uso de ventilación mecánica. El CURB-65 tuvo menor poder discriminatorio comparado con el IGN e INGAC. Conclusión: Los índices pronósticos validados en la literatura médica permiten predecir el riesgo de complicaciones y muerte en el adulto hospitalizado por neumonía neumocóccica. Sin embargo, difieren en su sensibilidad, especificidad y poder discriminatorio de los distintos eventos adversos.