Estadiamento do carcinoma do colo do útero por ressonância magnética – comparação com os achados anátomo-patológicos

Objectivo: Avaliar a acuidade da Ressonância Magnética (RM) no estadiamento do carcinoma do colo do útero, comparando os achados em RM com os resultados Anátomo-Patológicos da peça operatória. Material e Métodos: Foi efectuado um estudo retrospectivo que incluiu 41 doentes operadas com o diagnóstico de carcinoma do colo do útero e previamente submetidas a RM para estadiamento, entre Janeiro de 2007 e Dezembro de 2009. Foram analisados os seguintes factores de estadiamento e prognóstico: dimensão do tumor, invasão dos paramétrios, invasão da vagina e metástases ganglionares. A dimensão do tumor determinada por RM foi comparada com a medição na peça operatória através da análise do declive e ordenada na origem de uma recta de regressão entre os dois métodos. Resultados: O tumor foi visualizado por RM na maioria dos casos (35 doentes, 85.4%). Nas restantes 6 doentes a avaliação anátomo-patológica revelou um tumor com menos de 6 mm de diâmetro. A dimensão do tumor foi adequadamente avaliada por RM, sem diferenças estatisticamente significativas entre a medição por RM e na peça operatória. Foi confirmado o elevado valor preditivo negativo da RM na exclusão de invasão dos paramétrios previamente reportado, com apenas 2 falsos negativos em que a anatomia patológica demonstrou apenas invasão microscópica focal. A invasão da vagina foi correctamente avaliada em 30 doentes (85.7%), tendo-se verificado nos restantes casos 2 falsos negativos e 3 falsos positivos. Em relação às metástases ganglionares verificaram-se 4 falsos negativos, no total das 41 doentes avaliadas. Conclusão: A dimensão do tumor, invasão dos paramétrios, invasão da vagina e metástases ganglionares foram adequadamente avaliadas por RM, confirmando a capacidade da RM no estadiamento do carcinoma do colo do útero.

Towards person-centered neuroimaging markers for resilience and vulnerability in Bipolar Disorder

Improved clinical care for Bipolar Disorder (BD) relies on the identification of diagnostic markers that can reliably detect disease-related signals in clinically heterogeneous populations. At the very least, diagnostic markers should be able to differentiate patients with BD from healthy individuals and from individuals at familial risk for BD who either remain well or develop other psychopathology, most commonly Major Depressive Disorder (MDD). These issues are particularly pertinent to the development of translational applications of neuroimaging as they represent challenges for which clinical observation alone is insufficient. We therefore applied pattern classification to task-based functional magnetic resonance imaging (fMRI) data of the n-back working memory task, to test their predictive value in differentiating patients with BD (n=30) from healthy individuals (n=30) and from patients' relatives who were either diagnosed with MDD (n=30) or were free of any personal lifetime history of psychopathology (n=30). Diagnostic stability in these groups was confirmed with 4-year prospective follow-up. Task-based activation patterns from the fMRI data were analyzed with Gaussian Process Classifiers (GPC), a machine learning approach to detecting multivariate patterns in neuroimaging datasets. Consistent significant classification results were only obtained using data from the 3-back versus 0-back contrast. Using contrast, patients with BD were correctly classified compared to unrelated healthy individuals with an accuracy of 83.5%, sensitivity of 84.6% and specificity of 92.3%. Classification accuracy, sensitivity and specificity when comparing patients with BD to their relatives with MDD, were respectively 73.1%, 53.9% and 94.5%. Classification accuracy, sensitivity and specificity when comparing patients with BD to their healthy relatives were respectively 81.8%, 72.7% and 90.9%. We show that significant individual classification can be achieved using whole brain pattern analysis of task-based working memory fMRI data. The high accuracy and specificity achieved by all three classifiers suggest that multivariate pattern recognition analyses can aid clinicians in the clinical care of BD in situations of true clinical uncertainty regarding the diagnosis and prognosis.

The role of heart rate as a risk marker for predicting adverse outcomes

Cardiovascular disease is one of the leading causes of death around the world. Resting heart rate has been shown to be a strong and independent risk marker for adverse cardiovascular events and mortality, and yet its role as a predictor of risk is somewhat overlooked in clinical practice. With the aim of highlighting its prognostic value, the role of resting heart rate as a risk marker for death and other adverse outcomes was further examined in a number of different patient populations. A systematic review of studies that previously assessed the prognostic value of resting heart rate for mortality and other adverse cardiovascular outcomes was presented. New analyses of nine clinical trials were carried out. Both the original and extended Cox model that allows for analysis of time-dependent covariates were used to evaluate and compare the predictive value of baseline and time-updated heart rate measurements for adverse outcomes in the CAPRICORN, EUROPA, PROSPER, PERFORM, BEAUTIFUL and SHIFT populations. Pooled individual patient meta-analyses of the CAPRICORN, EPHESUS, OPTIMAAL and VALIANT trials, and the BEAUTIFUL and SHIFT trials, were also performed. The discrimination and calibration of the models applied were evaluated using Harrell’s C-statistic and likelihood ratio tests, respectively. Finally, following on from the systematic review, meta-analyses of the relation between baseline and time-updated heart rate, and the risk of death from any cause and from cardiovascular causes, were conducted. Both elevated baseline and time-updated resting heart rates were found to be associated with an increase in the risk of mortality and other adverse cardiovascular events in all of the populations analysed. In some cases, elevated time-updated heart rate was associated with risk of events where baseline heart rate was not. Time-updated heart rate also contributed additional information about the risk of certain events despite knowledge of baseline heart rate or previous heart rate measurements. The addition of resting heart rate to the models where resting heart rate was found to be associated with risk of outcome improved both discrimination and calibration, and in general, the models including time-updated heart rate along with baseline or the previous heart rate measurement had the highest and similar C-statistics, and thus the greatest discriminative ability. The meta-analyses demonstrated that a 5bpm higher baseline heart rate was associated with a 7.9% and an 8.0% increase in the risk of all-cause and cardiovascular death, respectively (both p less than 0.001). Additionally, a 5bpm higher time-updated heart rate (adjusted for baseline heart rate in eight of the ten studies included in the analyses) was associated with a 12.8% (p less than 0.001) and a 10.9% (p less than 0.001) increase in the risk of all-cause and cardiovascular death, respectively. These findings may motivate health care professionals to routinely assess resting heart rate in order to identify individuals at a higher risk of adverse events. The fact that the addition of time-updated resting heart rate improved the discrimination and calibration of models for certain outcomes, even if only modestly, strengthens the case that it be added to traditional risk models. The findings, however, are of particular importance, and have greater implications for the clinical management of patients with pre-existing disease. An elevated, or increasing heart rate over time could be used as a tool, potentially alongside other established risk scores, to help doctors identify patient deterioration or those at higher risk, who might benefit from more intensive monitoring or treatment re-evaluation. Further exploration of the role of continuous recording of resting heart rate, say, when patients are at home, would be informative. In addition, investigation into the cost-effectiveness and optimal frequency of resting heart rate measurement is required. One of the most vital areas for future research is the definition of an objective cut-off value for the definition of a high resting heart rate.

Índice del perfil del donante renal (KDPI) como factor pronóstico del trasplante

La enfermedad renal crónica ha aumentado a nivel mundial y nacional, mientras que el número de donantes viene en descenso, y los pacientes en lista de espera aumentan. Los donantes cadavéricos son una opción para estos pacientes, y han sido utilizados en últimos años para aumentar los órganos disponibles. La evaluación de la calidad de estos es importante para optimizar su uso. Estudio analítico tipo cohorte retrospectiva, cálculo de KDPI en donantes cadavéricos, seguimiento función renal creatinina sérica 1 mes, 3 meses, 6 meses y un año. Correlación supervivencia del injerto, función renal, KDPI y EPTS. Análisis de supervivencia y regresión logística con variables del donante, receptor y acto quirúrgico.

Modelo predictivo para uso del condón y consumo de alcohol como conductas de riesgo relacionadas con el contagio de VIH/SIDA en trabajadoras sexuales de Bogotá- 2015

Objetivo: Determinar un modelo predictivo para uso del condón y consumo de alcohol como conductas de riesgo relacionadas el contagio de VIH/Sida en mujeres trabajadoras sexuales de la ciudad de Bogotá en el año 2015. Métodos Estudio de tipo transversal con diseño observacional, se tomaron 255 mujeres trabajadoras sexuales de la ciudad de Bogotá; La información analizada fue tomada del estudio realizado en cinco ciudades de Colombia en el año 2015, las hipótesis planteadas se soportaron en la asociación entre las condiciones sociodemográficas, de conocimiento, practicas, hábitos, apoyo social y de ocupación propia de las mujeres trabajadoras sexuales que podían explicar y predecir la adopción de conductas riesgosas para VIH/sida como son el uso del condón y el consumo de alcohol en ejercicio de su ocupación. Resultados El promedio de edad de inicio en el trabajo sexual fue 22,1±7,1 años, tres cuartas partes son solteras y residen en estrato dos y tres; el 96,5% dijo usar el condón con el último cliente y el 27,8% de ellas consumió alcohol durante su último servicio. En la conducta de riesgo uso del condón, se encontraron asociados entre otras, la edad [OR=1,10(1,03-1,17)], vivir en estrato dos [OR=7,7(1,5-39,5)], el ingreso por trabajo sexual [OR=1,0(1,0-1,0)], la disponibilidad del condón para el servicio [OR=0,03(0,008-0,16)] y contar con otro método de planificación (ligadura de trompas) [OR=4,47(1,0-18,3)]. En la conducta de riesgo consumo de alcohol, se encontró asociado ente otros: estrato socioeconómico dos [OR=5,8(1,54-22,3)], nivel de escolaridad secundaria [OR=0,12(0,16-0,96)], vivir con otros familiares [OR=3,45(1,7-7,02)], ingreso por trabajo sexual [OR=1,0(1,0-1,0)] y el sitio donde se ofrece el servicio [OR=0,07(0,04-0,15)]. Después de ajustar, se encontró que las variables que mejor explican el uso del condón fueron edad [OR=1,1(1,02-1,17)] y disponibilidad del condón [OR=0,04(0,008-0,024)], el modelo tuvo poca sensibilidad 33,3% y buena capacidad predictiva (84,6%). Las variables que mejor explicaron el consumo de alcohol durante el servicio fueron edad [OR= 0,95(0,91-0,98)], Número de clientes por semana [OR=0,9(0,90-0,98)], sitio donde ofrece el servicio [OR=7,1(3,45-14,8)], y estrato socioeconómico [OR=1,8 (0,90-3,83)], resultando un modelo con buena sensibilidad (71,8%) y buena capacidad predictiva (86,4%). Conclusiones Aspectos como la edad, el estrato socioeconómico, escolaridad, estado civil, ingreso económico por trabajo sexual, edad de inicio en el trabajo sexual, número de clientes antiguos en la última semana, disponibilidad del condón para prestar el servicio y ligadura de trompas como método diferente de planificación, se asociaron estadísticamente con el uso del condón. Sin embargo al ajustar las variables solo la edad y la disponibilidad del condón se mantuvieron como variables explicativas. Cabe anotar, que aunque el modelo mostró buena capacidad predictiva (84,6%), la precisión en sus estimaciones fue baja debido a la poca frecuencia del no uso del condón con el ultimo cliente (3,5%), y la sensibilidad del modelo apenas fue del 33,3%. Por otro lado, factores como la edad, el estrato socioeconómico, nivel educativo, ingreso económico, sitio de oferta del servicio, composición familiar, número de hijos, número de clientes atendidos en la última semana y número de clientes antiguos mostraron asociación estadística con el consumo de alcohol. Sin embargo, al ajustar las variables solo edad, estrato socioeconómico, sitio donde se ofrece el servicio y número de clientes por semana mantuvieron asociación estadística; observándose además que el estrato socioeconómico (uno y dos) y sitio donde se ofrece el servicio (establecimiento), son factores de riesgo para el consumo de alcohol en ejercicio de la ocupación y la poca edad y un número reducido de clientes por semana se comportan como factores de protección para el consumo de alcohol. El modelo predictivo que se desarrolló para la conducta de riesgo de consumo de alcohol, con una sensibilidad del 71,8% y un poder predictivo del 86,4%. .

Evaluación del desempeño pronóstico de dos puntajes de predicción de mortalidad a siete días en pacientes adultos oncológicos críticamente enfermos admitidos a una unidad de cuidados intensivos en Bogotá

Introducción Los sistemas de puntuación para predicción se han desarrollado para medir la severidad de la enfermedad y el pronóstico de los pacientes en la unidad de cuidados intensivos. Estas medidas son útiles para la toma de decisiones clínicas, la estandarización de la investigación, y la comparación de la calidad de la atención al paciente crítico. Materiales y métodos Estudio de tipo observacional analítico de cohorte en el que reviso las historias clínicas de 283 pacientes oncológicos admitidos a la unidad de cuidados intensivos (UCI) durante enero de 2014 a enero de 2016 y a quienes se les estimo la probabilidad de mortalidad con los puntajes pronósticos APACHE IV y MPM II, se realizó regresión logística con las variables predictoras con las que se derivaron cada uno de los modelos es sus estudios originales y se determinó la calibración, la discriminación y se calcularon los criterios de información Akaike AIC y Bayesiano BIC. Resultados En la evaluación de desempeño de los puntajes pronósticos APACHE IV mostro mayor capacidad de predicción (AUC = 0,95) en comparación con MPM II (AUC = 0,78), los dos modelos mostraron calibración adecuada con estadístico de Hosmer y Lemeshow para APACHE IV (p = 0,39) y para MPM II (p = 0,99). El ∆ BIC es de 2,9 que muestra evidencia positiva en contra de APACHE IV. Se reporta el estadístico AIC siendo menor para APACHE IV lo que indica que es el modelo con mejor ajuste a los datos. Conclusiones APACHE IV tiene un buen desempeño en la predicción de mortalidad de pacientes críticamente enfermos, incluyendo pacientes oncológicos. Por lo tanto se trata de una herramienta útil para el clínico en su labor diaria, al permitirle distinguir los pacientes con alta probabilidad de mortalidad.

Hallazgos tomográficos como predictores del resultado funcional en edema macular secundario a oclusiones venosas retinianas

INTRODUCCIÓN: El Edema Macular (EM) es la principal causa de perdida de agudeza visual en pacientes con Oclusión Venosa Retiniana (OVR); luego del tratamiento, algunos pacientes persisten con mala agudeza visual. OBJETIVO: Realizar una Revisión Sistemática de la Literatura (RSL), para identificar la evidencia existente sobre factores tomográficos que predicen el resultado visual en pacientes con EM secundario a OVR. FUENTE DE LA INFORMACIÓN: PUBMED, MEDLINE, EMBASE, LILACS, COCHRANE, literatura gris. SELECCIÓN DE LOS ESTUDIOS: Ensayos Clínicos Controlados (ECC) y estudios observacionales analíticos. EXTRACCIÓN Y SÍNTESIS DE LOS DATOS: Dos investigadores seleccionaron los artículos de forma independiente. Se realizó una síntesis cualitativa de la información siguiendo las recomendaciones de la declaración PRISMA 2009. MEDIDAS Y DESENLACE PRINCIPAL: Grosor Retiniano Central (GRC), integridad de Banda Elipsoide e Integridad de Membrana Limitante Externa (MLE), determinados por SD OCT. El desenlace principal es la Agudeza Visual Mejor Corregida (AVMC) a los 6, 12,18 y/o 24 meses. RESULTADOS: Se identificaron 872 abstract y se incluyeron 8 artículos en el análisis cualitativo. Seis estudios evaluaron el GRC sin encontrar asociación con resultado visual final. Solo 2 estudios evaluaron y encontraron asociación estadísticamente significativa de la integridad de la MLE con el desenlace visual, Kang, H 2012 (r2 0,51 p 0,000), Rodriguez, F 2014 (p< 0,001). La integridad de la BE fue asociada a pronostico visual en 4 de 5 estudios que evaluaron esta variable, con resultados estadísticamente significativos. La AVMC de base también se asocio con desenlace visual en 4 de 5 estudios que la evaluaron. El mejor modelo que predice el resultado funcional según el estudio de Kang, H 2012 fue: Integridad de MLE, integridad de BE y AVMC de base (R2 0,671 p 0,000), a los 12 meses de seguimiento. CONCLUSION: La evidencia actual sugiere que la integridad de la BE y la MLE son predictores del resultados funcional en pacientes con EM secundario a OVR después de 6 o mas meses de seguimiento. Es necesario la realización de estudios controlados para llegar a resultados mas concluyentes.

A high-value, low-cost bubble continuous positive airway pressure system for low-resource settings:technical assessment and initial case reports

Acute respiratory infections are the leading cause of global child mortality. In the developing world, nasal oxygen therapy is often the only treatment option for babies who are suffering from respiratory distress. Without the added pressure of bubble Continuous Positive Airway Pressure (bCPAP) which helps maintain alveoli open, babies struggle to breathe and can suffer serious complications, and frequently death. A stand-alone bCPAP device can cost $6,000, too expensive for most developing world hospitals. Here, we describe the design and technical evaluation of a new, rugged bCPAP system that can be made in small volume for a cost-of-goods of approximately $350. Moreover, because of its simple design--consumer-grade pumps, medical tubing, and regulators--it requires only the simple replacement of a <$1 diaphragm approximately every 2 years for maintenance. The low-cost bCPAP device delivers pressure and flow equivalent to those of a reference bCPAP system used in the developed world. We describe the initial clinical cases of a child with bronchiolitis and a neonate with respiratory distress who were treated successfully with the new bCPAP device.

Prognostic value of sentinel node biopsy in 327 prospective melanoma patients from a single institution

AIM: To confirm the accuracy of sentinel node biopsy (SNB) procedure and its morbidity, and to investigate predictive factors for SN status and prognostic factors for disease-free survival (DFS) and disease-specific survival (DSS). MATERIALS AND METHODS: Between October 1997 and December 2004, 327 consecutive patients in one centre with clinically node-negative primary skin melanoma underwent an SNB by the triple technique, i.e. lymphoscintigraphy, blue-dye and gamma-probe. Multivariate logistic regression analyses as well as the Kaplan-Meier were performed. RESULTS: Twenty-three percent of the patients had at least one metastatic SN, which was significantly associated with Breslow thickness (p<0.001). The success rate of SNB was 99.1% and its morbidity was 7.6%. With a median follow-up of 33 months, the 5-year DFS/DSS were 43%/49% for patients with positive SN and 83.5%/87.4% for patients with negative SN, respectively. The false-negative rate of SNB was 8.6% and sensitivity 91.4%. On multivariate analysis, DFS was significantly worsened by Breslow thickness (RR=5.6, p<0.001), positive SN (RR=5.0, p<0.001) and male sex (RR=2.9, p=0.001). The presence of a metastatic SN (RR=8.4, p<0.001), male sex (RR=6.1, p<0.001), Breslow thickness (RR=3.2, p=0.013) and ulceration (RR=2.6, p=0.015) were significantly associated with a poorer DSS. CONCLUSION: SNB is a reliable procedure with high sensitivity (91.4%) and low morbidity. Breslow thickness was the only statistically significant parameter predictive of SN status. DFS was worsened in decreasing order by Breslow thickness, metastatic SN and male gender. Similarly DSS was significantly worsened by a metastatic SN, male gender, Breslow thickness and ulceration. These data reinforce the SN status as a powerful staging procedure

Prevalence of the hepatitis C virus among university employees in São Paulo, southeastern Brazil: predictive factors and geoprocessing spatial analysis

Background There are limited studies on the prevalence and risk factors associated with hepatitis C virus (HCV) infection. Objective Identify the prevalence and risk factors for HCV infection in university employees of the state of São Paulo, Brazil. Methods Digital serological tests for anti-HCV have been performed in 3153 volunteers. For the application of digital testing was necessary to withdraw a drop of blood through a needlestick. The positive cases were performed for genotyping and RNA. Chi-square and Fisher’s exact test were used, with P-value <0.05 indicating statistical significance. Univariate and multivariate logistic regression were also used. Results Prevalence of anti-HCV was 0.7%. The risk factors associated with HCV infection were: age >40 years, blood transfusion, injectable drugs, inhalable drugs (InDU), injectable Gluconergam®, glass syringes, tattoos, hemodialysis and sexual promiscuity. Age (P=0.01, OR 5.6, CI 1.4 to 22.8), InDU (P<0.0001, OR=96.8, CI 24.1 to 388.2), Gluconergam® (P=0.0009, OR=44.4, CI 4.7 to 412.7) and hemodialysis (P=0.0004, OR=90.1, CI 7.5 – 407.1) were independent predictors. Spatial analysis of the prevalence with socioeconomic indices, Gross Domestic Product and Human Development Index by the geoprocessing technique showed no positive correlation. Conclusions The prevalence of HCV infection was 0.7%. The independent risk factors for HCV infection were age, InDU, Gluconergan® and hemodialysis. There was no spatial correlation of HCV prevalence with local economic factors.

On existence and uniqueness of positive solutions to a class of fractional boundary value problems

[EN] The purpose of this paper is to investigate the existence and uniqueness of positive solutions for the following fractional boundary value problem D 0 + α u ( t ) + f ( t , u ( t ) ) = 0 , 0 < t < 1 , u ( 0 ) = u ( 1 ) = u ′ ( 0 ) = 0 , where 2 < α ≤ 3 and D 0 + α is the Riemann-Liouville fractional derivative. Our analysis relies on a fixed-point theorem in partially ordered metric spaces. The autonomous case of this problem was studied in the paper [Zhao et al., Abs. Appl. Anal., to appear], but in Zhao et al. (to appear), the question of uniqueness of the solution is not treated. We also present some examples where we compare our results with the ones obtained in Zhao et al. (to appear). 2010 Mathematics Subject Classification: 34B15

Existence and uniqueness of positive and nondecreasing solutions for a class of singular fractional boundary value problems

[EN] We establish the existence and uniqueness of a positive and nondecreasing solution to a singular boundary value problem of a class of nonlinear fractional differential equation. Our analysis relies on a fixed point theorem in partially ordered sets.

Global behavior of positive solutions of nonlinear three-point boundary value problems

We investigate the structure of the positive solution set for nonlinear three-point boundary value problems of the form u('') + h(t) f(u) = 0, u(0) = 0, u(1) = lambdau(eta), where eta epsilon (0, 1) is given lambda epsilon (0, 1/n) is a parameter, f epsilon C ([0, infinity), [0, infinity)) satisfies f (s) > 0 for s > 0, and h epsilon C([0, 1], [0, infinity)) is not identically zero on any subinterval of [0, 1]. Our main results demonstrate the existence of continua of positive solutions of the above problem. (C) 2004 Elsevier Ltd. All rights reserved.