Predictors of positive (18) F-FDG PET/CT-scan for large vessel vasculitis in patients with persistent polymyalgia rheumatica

Objective: Polymyalgia rheumatica (PMR) is often the presenting manifestation of giant cell arteritis (GCA). Fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) scan often discloses the presence of large vessel vasculitis (LVV) in PMR patients. We aimed to identify predictive factors of a positive PET/CT scan for LVV in patients classified as having isolated PMR according to well-established criteria. Methods: A set of consecutive patients with PMR from a single hospital were assessed. All of them underwent PET/CT scan between January 2010 and February 2018 based on clinical considerations. Patients with PMR associated to other diseases, including those with cranial features of GCA, were excluded. The remaining patients were categorized in classic PMR (if fulfilled the 2012 EULAR/ACR classification criteria at disease diagnosis; n=84) or atypical PMR (who did not fulfill these criteria; n=16). Only information on patients with classic PMR was assessed. Results: The mean age of the 84 patients (51 women) with classic PMR was 71.4±9.2 years. A PET/CT scan was positive in 51(60.7%). Persistence of classic PMR symptoms was the most common reason to perform a PET/CT scan. Nevertheless, patients with positive PET/CT scan often had unusual symptoms. The best set of predictors of a positive PET/CT scan were bilateral diffuse lower limb pain (OR=8.8, 95% CI 1.7-46.3; p=0.01), pelvic girdle pain (OR=4.9, 95% CI 1.50-16.53; p=0.01) and inflammatory low back pain (OR=4.7, 95% CI 1.03-21.5; p=0.04). Conclusion: Inflammatory low back pain, pelvic girdle and diffuse lower limb pain are predictors of positive PET/CT scan for LVV in PMR

Role of age and comorbidities in mortality of patients with infective endocarditis

[Purpose]: The aim of this study was to analyse the characteristics of patients with IE in three groups of age and to assess the ability of age and the Charlson Comorbidity Index (CCI) to predict mortality. [Methods]: Prospective cohort study of all patients with IE included in the GAMES Spanish database between 2008 and 2015.Patients were stratified into three age groups:<65 years,65 to 80 years,and ≥ 80 years.The area under the receiver-operating characteristic (AUROC) curve was calculated to quantify the diagnostic accuracy of the CCI to predict mortality risk. [Results]: A total of 3120 patients with IE (1327 < 65 years;1291 65-80 years;502 ≥ 80 years) were enrolled.Fever and heart failure were the most common presentations of IE, with no differences among age groups.Patients ≥80 years who underwent surgery were significantly lower compared with other age groups (14.3%,65 years; 20.5%,65-79 years; 31.3%,≥80 years). In-hospital mortality was lower in the <65-year group (20.3%,<65 years;30.1%,65-79 years;34.7%,≥80 years;p < 0.001) as well as 1-year mortality (3.2%, <65 years; 5.5%, 65-80 years;7.6%,≥80 years; p = 0.003).Independent predictors of mortality were age ≥ 80 years (hazard ratio [HR]:2.78;95% confidence interval [CI]:2.32–3.34), CCI ≥ 3 (HR:1.62; 95% CI:1.39–1.88),and non-performed surgery (HR:1.64;95% CI:11.16–1.58).When the three age groups were compared,the AUROC curve for CCI was significantly larger for patients aged <65 years(p < 0.001) for both in-hospital and 1-year mortality. [Conclusion]: There were no differences in the clinical presentation of IE between the groups. Age ≥ 80 years, high comorbidity (measured by CCI),and non-performance of surgery were independent predictors of mortality in patients with IE.CCI could help to identify those patients with IE and surgical indication who present a lower risk of in-hospital and 1-year mortality after surgery, especially in the <65-year group

Complement component C4 structural variation and quantitative traits contribute to sex-biased vulnerability in systemic sclerosis

Altres ajuts: Fondo Europeo de Desarrollo Regional (FEDER), "A way of making Europe".Copy number (CN) polymorphisms of complement C4 play distinct roles in many conditions, including immune-mediated diseases. We investigated the association of C4 CN with systemic sclerosis (SSc) risk. Imputed total C4, C4A, C4B, and HERV-K CN were analyzed in 26,633 individuals and validated in an independent cohort. Our results showed that higher C4 CN confers protection to SSc, and deviations from CN parity of C4A and C4B augmented risk. The protection contributed per copy of C4A and C4B differed by sex. Stronger protection was afforded by C4A in men and by C4B in women. C4 CN correlated well with its gene expression and serum protein levels, and less C4 was detected for both in SSc patients. Conditioned analysis suggests that C4 genetics strongly contributes to the SSc association within the major histocompatibility complex locus and highlights classical alleles and amino acid variants of HLA-DRB1 and HLA-DPB1 as C4-independent signals

¿Es la arteriografía preoperatoria un método tan infalible como se cree?

Introducción. Aunque la arteriografía se considera el patrón de referencia para la valoración de la arteriopatía periférica, la variabilidad en su interpretación es causa frecuente de disparidad diagnóstica y de tratamiento. Objetivo. Valorar la fiabilidad diagnóstica de la arteriografía preoperatoria y determinar la precisión y variabilidad interobservador, así como su implicación en la toma de decisiones terapéuticas. Pacientes y métodos. Se diseñó un estudio prospectivo en el que 100 angiografías de extremidades inferiores, seleccionadas aleatoriamente, se evaluaron de manera ciega e independiente por tres cirujanos vasculares. Las arterias se categorizaron como permeables, gravemente enfermas, ocluidas o no diagnóstica a diferentes niveles. La concordancia se expresó como valores k y se analizó la opción terapéutica propuesta por cada observador basada en la historia clínica y hallazgos angiográficos. Resultados. El porcentaje de segmentos arteriales no identificados en la arteriografía preoperatoria (no diagnósticos) fue sorprendentemente elevado: 18% tibial anterior, 21% tibial posterior, 28% peronea. La concordancia global fue buena en segmento aórtico (k = 0,78), ilíaco (k = 0,76), femoral (k = 0,61) y poplíteo supragenicular (k = 0,64); moderado para poplítea infragenicular (k = 0,50), y pobre para troncos tibiales (k = 0,22). Aunque en el 70% de casos los tres observadores propusieron idéntico tratamiento (k = 0,65, concordancia alta), en un 30% el plan terapéutico inicial basado en la angiografía preoperatoria no coincidía, y en un 19% de los casos este plan debió modificarse de acuerdo con los hallazgos intraoperatorios. Conclusiones. La importante variabilidad interobservador en la valoración de segmentos infrageniculares debe tenerse en cuenta cuando otros métodos diagnósticos se comparan con la angiografía preoperatoria. Este trabajo cuestiona su fiabilidad, enfatiza la necesidad de estudios angiográficos intraoperatorios y señala un importante sesgo en la interpretación de publicaciones cuando se intenta comparar esta prueba preoperatoria con respecto a otros métodos no invasivos

Mixoma intramuscular inguinal y compresión de elementos vasculonerviosos femorales

Introducción. La tumoraciones no pulsátiles inguinales son tratadas por cirujanos vasculares por su relación con los vasos femorales. El mixoma intramuscular es un caso raro de tumor benigno con tendencia a la compresión de las estructuras vecinas y con potencial de recidiva local. La resección completa con márgenes amplios es el tratamiento indicado para ellos. Caso clínico. Varón de 57 años. Clínica de parestesias en cara anteriomedial del muslo izquierdo, ausencia de patología vascular en la extremidad afectada. En la exploración, se palpa una masa inguinal bien delimitada, blanda, compresible, no fluctuante, adherida a planos profundos, no dolorosa a la palpación, de 10 cm de diámetro. En el estudio radiológico mediante tomografía axial computarizada y resonancia magnética, se demuestra una colección líquida de contorno liso y bien definido, en íntimo contacto con el músculo psoasilíaco que se prolonga por encima del anillo inguinal con imagen en ¿reloj de arena¿ con desplazamiento de vasos femorales y sospecha diagnóstica de bursitis. Tras la resección quirúrgica, el estudio anatomopatológico es compatible con el diagnóstico de mixoma intramuscular. Conclusión. Se trata de la primera descripción en la literatura de este tumor en esta localización anatómica y con la forma en ¿reloj de arena¿ a través del anillo inguinal. Constituye una posibilidad a tener en cuenta en tumores de partes blandas en la región inguinal

Valor diagnóstico de la ecografía Doppler color en el control clínico de la reparación endovascular de los aneurismas de aorta abdominal

Introducción. El control clínico del tratamiento endovascular de la enfermedad aneurismática de la aorta abdominal se basa en la valoración de la evolución del tamaño del aneurisma, la permeabilidad de la endoprótesis y la detección de fugas. Objetivo. Comparar la ecografía Doppler (ED) color con la tomografía axial computarizada (TAC) en la evaluación del tamaño del aneurisma y la detección de fugas en el tratamiento endovascular de aneurismas de aorta abdominal. Pacientes y métodos. Estudio prospectivo entre enero y diciembre de 2005. En 14 pacientes sometidos a tratamiento endovascular se realizó ED color y TAC a 1, 6 y 12 meses. Se compararon los tamaños del aneurisma mediante la prueba t para muestras dependientes y estudio de correlación. Sensibilidad, especificidad, valor predictivo positivo y valor predictivo negativo y el coeficiente de concordancia kappa se calcularon para la detección de fugas. Resultados. El control clínico medio fue de 9,4 meses y se compararon 49 exploraciones. El diámetro medio del aneurisma a los tres meses de control clínico fue de 51,2 cm con ED color y de 52,5 cm con TAC (p = no significativo). El coeficiente de correlación ascendió a 0,97 (p < 0,001). Todos los dispositivos se mantuvieron permeables. En detección de fugas, el estudio ED color obtuvo una sensibilidad, especificidad, valor predictivo positivo y valor predictivo negativo de 75, 61, 20 y 95%, respectivamente (kappa = 0,61). Conclusiones. El estudio ED color obtiene una excelente correlación con la TAC en la medida del tamaño de los aneurismas. En cambio, posee un valor predictivo positivo muy bajo para la detección de fuga

Efecto de la trombosis carotídea en el comportamiento hemodinámico de la estenosis contralateral: criterios para su determinación

To compare the accuracy of various duplex hemodynamic criteria in grading ipsilateral carotid stenosis in patients with contralateral occlusion. PATIENTS AND METHODS. A prospective study was designed with 76 patients who had unilateral carotid occlusion, the results of duplex were correlated in blind fashion to arteriography. Each carotid was classified in order to the angiographic stenotic grade in: 1-29% (n = 39), 30-49% (n = 15), 50-69% (n = 14), &ge 70% (n = 8). Five duplex ultrasonography classification criteria for discriminate > 50% stenosis were used: Washington University (standard), AbuRahma (peak systolic velocity, PSV > 140 cm/s; diastolic velocity, EDV 140 cm/s; EDV 1.5; new method (ratio ICA/ CCA > 1.3; PSV > 115 cm/s). The sensibility, specificity, positive predictive value, negative predictive value, accuracy and k index were calculated. RESULTS. Best concordance between angiography and duplex was for the new method, providing a &kappa = 0.59 and an accuracy of 84.2, followed by standard method that obtained &kappa = 0.53 and an accuracy of 82.8. Specific methods for patients with unilateral occlusion of ICA (AbuRahma and Fujitani) provided inferior efficacy in detecting carotid stenosis ³ 50%, although the ratio method obtained intermediate results. CONCLUSIONS. The fact of having a contralateral occlusion of the ICA produces some overestimation or underestimation of the ipsilatral carotid stenosis degree following the classic criteria. This problem can be reduced using a ratio > 1.3 and a PSV > 115 cm/s. Each laboratory should perform an objective evaluation of their own criteria of diagnosis to discriminate hemodynamically significant lesions.Objetivo. Comparar la precisión diagnóstica de varios parámetros hemodinámicos en la graduación de la estenosis carotídea en pacientes con oclusión contralateral. Pacientes y métodos. Se diseñó un estudio prospectivo de 76 pacientes con oclusión carotídea unilateral, en el que se correlacionaron de manera ciega los hallazgos de eco-Doppler color y arteriografía. Cada carótida se clasificó, según el grado estenótico angiográfico, en: 1-29% (n = 39), 30-49% (n = 15), 50-69% (n = 14), &ge 70% (n = 8). Se consideraron cinco criterios hemodinámicos para valorar una estenosis > 50%: Universidad de Washington (estándar); AbuRahma (pico de velocidad sistólica, PSV > 140 cm/s; velocidad diastólica final, EDV 140 cm/s; EDV 1,5; y método nuevo (ratio de la ICA/CCA > 1,3; PSV > 115 cm/s). Se calcularon la sensibilidad, la especificidad, los valores predictivos positivo y negativo, el valor diagnóstico y el índice de concordancia k. Resultados. La mejor concordancia arteriografía/eco-Doppler se dio para el método nuevo (&kappa = 0,59), con una precisión diagnóstica del 84,2, seguida del método estándar (que obtuvo una &kappa = 0,53 y una precisión de 82,8). Los métodos específicos para pacientes con trombosis carotídea unilateral (AbuRahma y Fujitani) fueron los menos eficaces, mientras que el método de la ratio presentó resultados intermedios. Conclusiones. La presencia de oclusión produce una sobreestimación o infraestimación del grado estenótico ipsilateral según los criterios clásicos admitidos. Este problema puede reducirse mediante la utilización de una ratio > 1,3 y un PSV > 115 cm/s. Para evaluar el grado de progresión de la enfermedad carotídea cada laboratorio ha de validar sus propios criterios, los cuales deben permitir diferenciar entre lesiones hemodinámicamente significativas y aquellas que no lo son

How to Improve Healthcare for Patients with Multimorbidity and Polypharmacy in Primary Care: A Pragmatic Cluster-Randomized Clinical Trial of the MULTIPAP Intervention

Del Cura-Gonzalez I, Lopez-Rodriguez JA, Leiva-Fernandez F, et al. How to Improve Healthcare for Patients with Multimorbidity and Polypharmacy in Primary Care: A Pragmatic Cluster-Randomized Clinical Trial of the MULTIPAP Intervention. Journal of Personalized Medicine . 2022;12(5): 752.(1) Purpose: To investigate a complex MULTIPAP intervention that implements the Ariadne principles in a primary care population of young-elderly patients with multimorbidity and polypharmacy and to evaluate its effectiveness for improving the appropriateness of prescriptions. (2) Methods: A pragmatic cluster-randomized clinical trial was conducted involving 38 family practices in Spain. Patients aged 65-74 years with multimorbidity and polypharmacy were recruited. Family physicians (FPs) were randomly allocated to continue usual care or to provide the MULTIPAP intervention based on the Ariadne principles with two components: FP training (eMULTIPAP) and FP patient interviews. The primary outcome was the appropriateness of prescribing, measured as the between-group difference in the mean Medication Appropriateness Index (MAI) score change from the baseline to the 6-month follow-up. The secondary outcomes were quality of life (EQ-5D-5L), patient perceptions of shared decision making (collaboRATE), use of health services, treatment adherence, and incidence of drug adverse events (all at 1 year), using multi-level regression models, with FP as a random effect. (3) Results: We recruited 117 FPs and 593 of their patients. In the intention-to-treat analysis, the between-group difference for the mean MAI score change after a 6-month follow-up was -2.42 (95% CI from -4.27 to -0.59) and, between baseline and a 12-month follow-up was -3.40 (95% CI from -5.45 to -1.34). There were no significant differences in any other secondary outcomes. (4) Conclusions: The MULTIPAP intervention improved medication appropriateness sustainably over the follow-up time. The small magnitude of the effect, however, advises caution in the interpretation of the results given the paucity of evidence for the clinical benefit of the observed change in the MAI

Impact of late presentation of HIV infection on short-, mid- and long-term mortality and causes of death in a multicenter national cohort : 2004-2013

To analyze the impact of late presentation (LP) on overall mortality and causes of death and describe LP trends and risk factors (2004-2013). Cox models and logistic regression were used to analyze data from a nation-wide cohort in Spain. LP is defined as being diagnosed when CD4 < 350 cells/ml or AIDS. Of 7165 new HIV diagnoses, 46.9% (CI:45.7-48.0) were LP, 240 patients died.First-year mortality was the highest (aHR = 10.3[CI:5.5-19.3]); between 1 and 4 years post-diagnosis, aHR = 1.9(1.2-3.0); an

Prediction of long-term outcomes of HIV-infected patients developing non-AIDS events using a multistate approach

Outcomes of people living with HIV (PLWH) developing non-AIDS events (NAEs) remain poorly defined. We aimed to classify NAEs according to severity, and to describe clinical outcomes and prognostic factors after NAE occurrence using data from CoRIS, a large Spanish HIV cohort from 2004 to 2013. Prospective multicenter cohort study. Using a multistate approach we estimated 3 transition probabilities: from alive and NAE-free to alive and NAE-experienced ("NAE development"); from alive and NAE-experienced to death ("Death after NAE"); and from alive and NAE-free to death ("Death without NAE"). We analyzed the effect of different covariates, including demographic, immunologic and virologic data, on death or NAE development, based on estimates of hazard ratios (HR). We focused on the transition "Death after NAE". 8,789 PLWH were followed-up until death, cohort censoring or loss to follow-up. 792 first incident NAEs occurred in 9.01% PLWH (incidence rate 28.76; 95% confidence interval [CI], 26.80-30.84, per 1000 patient-years). 112 (14.14%) NAE-experienced PLWH and 240 (2.73%) NAE-free PLWH died. Adjusted HR for the transition "Death after NAE" was 12.1 (95%CI, 4.90-29.89). There was a graded increase in the adjusted HRs for mortality according to NAE severity category: HR (95%CI), 4.02 (2.45-6.57) for intermediate-severity; and 9.85 (5.45-17.81) for serious NAEs compared to low-severity NAEs. Male sex (HR 2.04; 95% CI, 1.11-3.84), ag