Search

Purpose Analyse the impact of different prognostic factors on G2-late vaginal complications after vaginal brachytherapy (VBT) ± external beam radiotherapy (EBRT) in postoperative endometrial cancer (PEC). Methods One hundred and twenty-six PEC patients treated with VBT ± EBRT were retrospectively analysed considering age, body mass index, applicator diameter, clinical target volume (CTV), use of dilators, chemotherapy and EQD2(α/β=3) at the most exposed 2 cm3 of the CTV as prognostic factors for vaginal complications. Late vaginal complications were evaluated using objective LENT-SOMA criteria. Statistics: descriptive analysis, Chi-square, Fisher and Student tests were applied. Univariate and multivariate analyses were performed with the Baptista–Pike exact method and multiple logistic regression. Results Mean age was 65 years (SD ± 10), and median follow-up was 66 months (8–104). 19/126 patients (15%) showed G2-late vaginal complications, and 107/126 (85%) G0–G1. Univariate analysis showed: CTV ≤ 9 cm3 (p = 0.036), use of dilators p = 0.015), and total ≥ 68 Gy EQD2 received by 2 cm3 of CTV (p = 0.039) were associated with G2-late vaginal toxicity. Multivariate analysis showed the use of dilators p = 0.043, OR 8.59, CI 1.59–159.9). Conclusion The use of dilators

Aims Because evidence regarding risk stratification predicting prognosis of patients with heart failure (HF) decompensation attended in primary care is lacking, we developed and externally validated a model to forecast death/hospitalization during the first 30 days after an episode of decompensation. The predictive model is based on variables easily obtained in primary care settings. Methods and results HEFESTOS is a multinational study consisting of a derivation cohort of HF patients recruited in 14 primary healthcare centres in Barcelona and a validation cohort from primary healthcare in 9 other European countries. The derivation and validation cohorts included 561 and 250 patients, respectively. Percentages of women in the derivation and validation cohorts were 56.3% and 47.6% (P = 0.026), respectively. Mean age was 82.2 years (SD 8.03) in the derivation cohort, and 79.3 years (SD 10.3) in the validation one (P = 0.001). HF with preserved ejection fraction represented 72.1% in the derivation cohort and 58.8% in the validation one (P = 0.004). Mortality/hospitalization during the first 30 days after a decompensation episode was 30.5% and 26% (P = 0.225) for the derivation and validation cohorts, respectively. Multivariable logistic regression models were performed to develop a score of risk. The identified predictors were worsening of dyspnoea [odds ratio (OR): 2.5; P = 0.001], orthopnoea (OR: 2.16; P = 0.01), paroxysmal nocturnal dyspnoea (OR: 2.25; P = 0.01), crackles (OR: 2.35; P = 0.01), New York Heart Association functional class III/IV (OR: 2.11; P = 0.001), oxygen saturation ≤ 90% (OR: 4.98; P 100 b.p.m. (OR: 2.72; P = 0.002), and previous hospitalization due to HF (OR: 2.45; P 20%. Outcome incidence was 2.7% for the low‐risk group, 12.8% for medium risk, and 46.2% for high risk in the derivation cohort, and 9.1%, 12.9%, and 39.6% in the validation one. Conclusions The HEFESTOS score, based on variables easily accessible in a community setting and validated in an external European cohort, properly predicted the risk of death/hospitalization during the first 30 days after an HF decompensation episode.

Resumen Introduccion y objetivo El dolor miofascial pelvico cronico es una patologia con una elevada prevalencia, y de etiologia muy diversa, al igual que su tratamiento. No se ha establecido un protocolo de tratamiento, y hasta el momento, se recomienda un abordaje multidisciplinar. El objetivo es evaluar el efecto de un protocolo basado en 10 sesiones de tecnicas de induccion miofascial (TIM) en pacientes con dolor miofascial pelvico cronico (DMPC). Material y metodos Se realizo un estudio cuasi experimental (antes-despues), con una intervencion basada en TIM adaptadas a la localizacion del dolor de los pacientes. Se evaluo la intensidad del dolor mediante la escala visual analogica (EVA) y la calidad de vida, tanto fisica como mental, mediante el cuestionario de salud SF-12v2. Para valorar el efecto de las TIM, se compararon los resultados preintervencion-postintervencion mediante la prueba t de Student para datos apareados y el test no parametrico de Wilcoxon. Resultados Se incluyeron 50 pacientes en el estudio (27 mujeres y 23 hombres), con una edad media de 44,8 anos (desviacion estandar [DE] 12,1) y una duracion media de los sintomas de 58,3 meses (DE 60,5). El analisis por protocolo mostro que la intensidad del dolor disminuyo en 3,99 puntos al final de la intervencion y la calidad de vida mejoro en los sumatorios fisico y mental en 5,45 y 5,87 puntos, respectivamente (p Conclusiones En un grupo de pacientes con dolor miofascial pelvico cronico, las TIM parecen tener un efecto beneficioso significativo, reduciendo el dolor y mejorando la calidad de vida.

Tuberculosis (TB) is a major cause of morbidity and mortality in children, and early diagnosis and treatment are crucial to reduce long-term morbidity and mortality. In this study, we explore whether urine nuclear magnetic resonance (NMR)-based metabolomics could be used to identify differences in the metabolic response of children with different diagnostic certainty of TB. We included 62 children with signs and symptoms of TB and 55 apparently healthy children. Six of the children with presumptive TB had bacteriologically confirmed TB, 52 children with unconfirmed TB, and 4 children with unlikely TB. Urine metabolic fingerprints were identified using high- and low-field proton NMR platforms and assessed with pattern recognition techniques such as principal components analysis and partial least squares discriminant analysis. We observed differences in the metabolic fingerprint of children with bacteriologically confirmed and unconfirmed TB compared to children with unlikely TB (p = 0.041 and p = 0.013, respectively). Moreover, children with unconfirmed TB with X-rays compatible with TB showed differences in the metabolic fingerprint compared to children with non-pathological X-rays (p = 0.009). Differences in the metabolic fingerprint in children with different diagnostic certainty of TB could contribute to a more accurate characterisation of TB in the paediatric population. The use of metabolomics could be useful to improve the prediction of TB progression and diagnosis in children.

The HEFESTOS scale was developed in 14 Spanish primary care centres and validated in 9 primary care centres of other European countries. It showed good performance to predict death/hospitalisation during the first 30 days after an episode of acute heart failure (AHF), with c-statistics of 0.807/0.730 in the derivation/validation cohorts. We evaluated this scale in the emergency department (ED) setting, comparing it to the EHMRG and MEESSI scales in the ED and the EFFECT and GWTG scales in hospitalised patients, to predict 30-day outcomes, including death and hospitalisation. Consecutive AHF patients were enrolled in 34 Spanish EDs in January-February 2016, 2018, and 2019 with variables needed to calculate outcome scores. Thirty-day hospitalisation/death (together and separately) and post-discharge combined adverse event (ED revisit or hospitalisation for AHF or all-cause death) were determined for patients discharged home after ED care. Predictive capacity was assessed by c-statistic with 95% confidence intervals. Of 10,869 patients, 4,044 were included (median age: 83 years, 54% women). The performance of HEFESTOS was modest for 30-day hospitalisation/death, c-statistic=0.656 (0.637-0.675), hospitalisation, 0.650 (0.631-0.669), and death, 0.610 (0.576-0.644). Of 1,034 patients with scores for the 5 scales, HEFESTOS had the numerically highest c-statistic for hospitalisation/death at 30 days, 0.666 (0.627-0.704), vs. MEESSI= 0.650 (0.612-0.687, p=0.51), EFFECT=0.633 (0.595-0.672, p=0.21), GWTG=0.618 (0.578-0.657, p=0.06) and EHMRG=0.617 (0.577-0.704, p=0.07). Similar modest performances were observed for predicting hospitalisation [ranging from HEFESTOS=0.656 (0.618-0.695) to GWTG=0.603 (0.564-0.643)]. Conversely, prediction of 30-day death was good with the MEESSI=0.787 (0.728-845), EFFECT=0.754 (0.691-0.818) and GWTG=0.749 (0.689-0.809) scales, and modest with EHMRG=0.649 (0.581-0.717) and HEFESTOS=0.610 (0.538-0.683). Although the HEFESTOS scale was numerically better for predicting 30-day hospitalisation/death in ED AHF patients, its modest performance precludes routine use. Only 30-day mortality was adequately predicted by some scales, with the MEESSI achieving the best results.

Diabetes; Hpertension; Prediction models Diabetes; Hipertensión; Modelos de predicción Diabetis; Hipertensió; Models de predicció Background Several scores to identify patients at high risk of suffering atrial fibrillation have been developed. Their applicability in hypertensive diabetic patients, however, remains uncertain. Our aim is to develop and validate a diagnostic predictive model to calculate the risk of developing atrial fibrillation at five years in a hypertensive diabetic population. Methods The derivation cohort consisted of patients with both hypertension and diabetes attended in any of the 52 primary healthcare centres of Barcelona; the validation cohort came from the 11 primary healthcare centres of Terres de l’Ebre (Catalonia South) from January 2013 to December 2017. Multivariable Cox regression identified clinical risk factors associated with the development of atrial fibrillation. The overall performance, discrimination and calibration of the model were carried out. Results The derivation data set comprised 54 575 patients. The atrial fibrillation rate incidence was 15.3 per 1000 person/year. A 5-year predictive model included age, male gender, overweight, heart failure, valvular heart disease, peripheral vascular disease, chronic kidney disease, number of antihypertensive drugs, systolic and diastolic blood pressure, heart rate, thromboembolism, stroke and previous history of myocardial infarction. The discrimination of the model was good (c-index = 0.692; 95% confidence interval, 0.684-0.700), and calibration was adequate. In the validation cohort, the discrimination was lower (c-index = 0.670). Conclusions The model accurately predicts future atrial fibrillation in a population with both diabetes and hypertension. Early detection allows the prevention of possible complications arising from this disease.

Objective: To evaluate the precipitating factors for heart failure decompensation in primary care and associations with short-term prognosis. Design Prospective cohort study with a 30-d follow-up from an index consultation. Regression models to determine independent factors associated with hospitalisation or death. Setting: Primary care in ten European countries. Patients Patients with diagnosis of heart failure attended in primary care for a heart failure decompensation (increase of dyspnoea, unexplained weight gain or peripheral oedema). Main outcome measures: Potential precipitating factors for decompensation of heart failure and their association with the event of hospitalisation or mortality 30 d after a decompensation. Results: Of 692 patients 54% were women, mean age 81 (standard deviation [SD] 8.9) years; mean left ventricular ejection fraction (LVEF) 55% (SD 12%). Most frequently identified heart failure precipitation factors were respiratory infections in 194 patients (28%), non-compliance of dietary recommendations in 184 (27%) and non-compliance with pharmacological treatment in 157 (23%). The two strongest precipitating factors to predict 30 d hospitalisation or death were respiratory infections (odds ratio [OR] 2.8, 95% confidence interval [CI] (2.4-3.4)) and atrial fibrillation (AF) > 110 beats/min (OR 2.2, CI 1.5-3.2). Multivariate analysis confirmed the association between the following variables and hospitalisation/death: In relation to precipitating factors: respiratory infection (OR 1.19, 95% CI 1.14-1.25) and AF with heart rate > 110 beats/min (OR 1.22, 95% CI 1.10-1.35); and regarding patient characteristics: New York Heart Association (NYHA) III or IV (OR 1.22, 95% CI 1.15-1.29); previous hospitalisation (OR 1.15, 95% CI 1.11-1.19); and LVEF < 40% (OR 1.14, 95% CI 1.09-1.19). Conclusions: In primary care, respiratory infections and rapid AF are the most important precipitating factors for hospitalisation and death within 30 d following an episode of heart failure decompensation. Key points Hospitalisation due to heart failure decompensation represents the highest share of healthcare costs for this disease. So far, no primary care studies have analysed the relationship between precipitating factors and short term prognosis of heart failure decompensation episodes. We found that in 692 patients with heart failure decompensation in primary care, the respiratory infection and rapid atrial fibrillation (AF) increased the risk of short-term hospital admission or death. Patients with a hospital admission the previous year and a decompensation episode caused by respiratory infection were even more likely to be hospitalized or die within 30 d.

Background Heart failure (HF) is a chronic condition that usually leads to death a few years after diagnosis. Although several clinical factors have been found to be related to increased mortality, less is known about the impact of social context, especially at the end stage of the disease. Knowing about social context is important to properly classify risk and provide holistic management for patients with advanced HF. Objective The aim of this study was to determine the impact of social context on mortality in patients with advanced HF. Methods A retrospective cohort study was conducted using data from clinical records on community-dwelling patients with HF and with New York Heart Association IV functional class living in Catalonia in northeastern Spain. Clinical data, patient dependency for basic activities of daily living, and social assessments were collected between 2010 and 2013. The primary outcome was all-cause mortality. Results Data from 1148 New York Heart Association class IV patients were analyzed. Mean (SD) age was 82 (9.0) years, and 61.7% were women. The mean (SD) follow-up was 18.2 (11.9) months. Mortality occurred in 592 patients. Social risk was identified in 63.6% of the patients, and 9.3% acknowledged having social problems. In the adjusted multivariate model, being male (hazard ratio (HR), 1.82; 95% confidence interval [CI], 1.16-2.83), having high dependency on others for basic activities of daily living (HR, 2.16; 95% CI, 1.21-3.85), and presenting with a social problem (HR, 2.46; 95% CI, 1.22-4.97) were related to an increased risk of mortality. Conclusions An unfavorable social profile is an independent risk factor for mortality in patients with advanced HF.

Background Frailty in older adults is a common multidimensional clinical entity, a state of vulnerability to stressors that increases the risk of adverse outcomes such as functional decline, institutionalization or death. The aim of this study is to identify the factors that anticipate the future inclusion of community-dwelling individuals aged ≥70 years in home care programmes (HC) and nursing homes (NH), and to develop the corresponding prediction models. Methods A prospective cohort study was conducted in 23 primary healthcare centers located in Catalonia, Spain, with an eight-year follow-up (2005–2013). The cohort was made up of 616 individuals. Data collection included a baseline multidimensional assessment carried out by primary health care professionals. Outcome variables were collected during follow-up by consulting electronic healthcare records, and the Central Registry of Catalonia for mortality. A prognostic index for a HC and NH at 8 years was estimated for each patient. Death prior to these events was considered a competing risk event, and Fine–Gray regression models were used. Results At baseline, mean age was 76.4 years and 55.5% were women. During follow-up, 19.2% entered a HC program, 8.2% a NH, and 15.4% died without presenting an event. Of those who entered a NH, 31.5% had previously been in a HC program. Multivariate models for a HC and NH showed that the risk of a HC entry was associated with older age, dependence on the Instrumental Activities of Daily Living, and slow gait measured by Timed-up-and-go test. An increased risk of being admitted to a NH was associated with older age, dependence on the Instrumental Activities of Daily Living, number of prescriptions, and the presence of social risk. Conclusions Prognostic models based on comprehensive geriatric assessments can predict the need for the commencement of HC and NH admission in community-dwelling older adults. Our findings underline the necessity to measure functional capacity, mobility, number of prescriptions, and social aspects of older adults in primary healthcare centers. In such a setting they can be offered longitudinal holistic assessments so as to benefit from preventive actions in order to remain independent in the community for as long as possible.

Background: Information regarding short-term vital prognosis in patients with heart failure at advanced stages of the disease is scarce. Objective: To develop a three-month mortality predictive model for patients with advanced heart failure. Methods: Prospective observational study carried out in primary care and a convalescence community facility. Heart failure patients either New York Heart Association (NYHA) III with at least two HF hospitalizations during the previous six months or NYHA IV with/without previous recent hospitalization were included in the study. Multivariable predictive models using Cox regression were performed. Results: Of 271 patients included, 55 (20.3%) died during the first three months of follow-up. Mean age was 84.2 years (SD 8.3) and 59.8% were women. Predictive model including NT-proBNP had a C-index of 0.78 (95% CI 0.71; 0.85) and identified male gender, low body mass index, high potassium and NT-proBNP levels, and moderate-to-severe dependence for daily living activities (Barthel index < 40) as risk factors of mortality. In the model without NT-proBNP, C index was 0.72 (95% CI 0.64; 0.79) and, in addition to gender, body mass index, low Barthel index, and severe reductions in glomerular filtration rate showed the highest predictive hazard ratios for short-term mortality. Conclusions: In addition to age, male gender, potassium levels, low body mass index, and low glomerular filtration, dependence for activities of daily living add strong power to predict mortality at three months in patients with advanced heart failure.

A logistic regression with random effects model is commonly applied to analyze clustered binary data, and every cluster is assumed to have a different proportion of success. However, it could be of interest to obtain the proportion of success over clusters (i.e. the marginal proportion of success). Furthermore, the degree of correlation among data of the same cluster (intraclass correlation) is also a relevant concept to assess, but when using logistic regression with random effects it is not possible to get an analytical expression of the estimators for marginal proportion and intraclass correlation. In our paper, we assess and compare approaches using different kinds of approximations: based on the logistic-normal mixed effects model (LN), linear mixed model (LMM), and generalized estimating equations (GEE). The comparisons are completed by using two real data examples and a simulation study. The results show the performance of the approaches strongly depends on the magnitude of the marginal proportion, the intraclass correlation, and the sample size. In general, the reliability of the approaches get worsen with low marginal proportion and large intraclass correlation. LMM and GEE approaches arises as reliable approaches when the sample size is large.

BackgroundInformation regarding the effect of social determinants of health on heart failure (HF) community-dwelling patients is scarce. We aimed to analyse the presence of socioeconomic inequalities, and their impact on hospitalisations and mortality, in patients with HF attended in a universal healthcare coverage system.MethodsA retrospective cohort study carried out in patients with HF aged >40 and attended at the 53 primary healthcare centres of the Institut Català de la Salut in Barcelona (Spain). Socioeconomic status (SES) was determined by an aggregated deprivation index (MEDEA). Cox proportional hazard models and competing-risks regression based on Fine and Gray’s proportional subhazards were performed to analyse hospitalisations due to of HF and total mortality that occurred between 1 January 2009 and 31 December 2012.ResultsMean age was 78.1 years (SD 10.2) and 56% were women. Among the 8235 patients included, 19.4% died during the 4 years of follow-up and 27.1% were hospitalised due to HF. A gradient in the risk of hospitalisation was observed according to SES with the highest risk in the lowest socioeconomic group (sHR 1.46, 95% CI 1.27 to 1.68). Nevertheless, overall mortality did not differ among the socioeconomic groups.ConclusionsIn spite of finding a gradient that linked socioeconomic deprivation to an increased risk of hospitalisation, there were no differences in mortality regarding SES in a universal healthcare coverage system.

Background: SARS-CoV-2 has caused a high mortality in institutionalised individuals. There are very few studies on the involvement and the real impact of COVID-19 in nursing homes. This study analysed factors related to morbidity and mortality of COVID-19 in institutionalised elderly people. Methods: This cohort study included 842 individuals from 12 nursing homes in Sant Cugat del Vallès (Spain) from 15 March to 15 May 2020. We evaluated individual factors (demographic, dependence, clinical, and therapeutic) and those related to the nursing homes (size and staff) associated with infection and mortality by SARS-CoV-2. Infection was diagnosed by molecular biology test. Results: Of the 842 residents included in the analysis, 784 underwent a Polymerase Chain Reaction (PCR) test, 74.2% were women, the mean age was 87.1 years, and 11.1% died. The PCR test was positive in 44%. A total of 33.4% of the residents presented symptoms compatible with COVID-19 and of these, 80.9% were PCR-positive for SARS-CoV-2. Infection by SARS-CoV-2 among residents was associated with the rate of staff infected in the homes. Mortality by SARS-CoV-2 was related to male sex and a greater grade of dependence measured with the Barthel index. Conclusions: SARS-Cov-2 infection in institutionalised people is associated with the infection rate in nursing home workers and mortality by SARS-Cov-2 with sex and greater dependency according to the Barthel index. Adequate management of nursing home staff and special attention to measures of infection control, especially of individuals with greater dependence, are keys for successful management of future pandemic situations.

Two key aims of diagnostic research are to accurately and precisely estimate disease prevalence and test sensitivity and specificity. Latent class models have been proposed that consider the correlation between subject measures determined by different tests in order to diagnose diseases for which gold standard tests are not available. In some clinical studies, several measures of the same subject are made with the same test under the same conditions (replicated measurements), and thus, replicated measurements for each subject are not independent. In the present study, we propose an extension of the Bayesian latent class Gaussian random effects model to fit the data with binary outcomes for tests with replicated subject measures. We describe an application using data collected on hookworm infection carried out in the municipality of Presidente Figueiredo, Amazonas State, Brazil. In addition, the performance of the proposed model was compared with that of current models (the subject random effects model and the conditional (in)dependent model) through a simulation study. As expected, the proposed model presented better accuracy and precision in the estimations of prevalence, sensitivity and specificity. Copyright © 2017 John Wiley & Sons, Ltd.

Background Despite their marginal benefit, about 60% of acute lower respiratory tract infections (ALRTIs) are currently treated with antibiotics in Catalonia. This study aims to evaluate the effectiveness and efficiency of a continuous disease-focused intervention (C-reactive protein [CRP]) and an illness-focused intervention (enhancement of communication skills to optimise doctor-patient consultations) on antibiotic prescribing in patients with ALRTIs in Catalan primary care centres. Methods/design A cluster randomised, factorial, controlled trial aimed at including 20 primary care centres (N = 2940 patients) with patients older than 18 years of age presenting for a first consultation with an ALRTI will be included in the study. Primary care centres will be identified on the basis of socioeconomic data and antibiotic consumption. Centres will be randomly assigned according to hierarchical clustering to any of four trial arms: usual care, CRP testing, enhanced communication skills backed up with patient leaflets, or combined interventions. A cost-effectiveness and cost-utility analysis will be performed from the societal and national healthcare system perspectives, and the time horizon of the analysis will be 1 year. Two qualitative studies (pre- and post-clinical trial) aimed to identify the expectations and concerns of patients with ALRTIs and the barriers and facilitators of each intervention arm will be run. Family doctors and nurses assigned to the interventions will participate in a 2-h training workshop before the inception of the trial and will receive a monthly intervention-tailored training module during the year of the trial period. Primary outcomes will be antibiotic use within the first 6 weeks, duration of moderate to severe cough, and the quality-adjusted life-years. Secondary outcomes will be duration of illness and severity of cough measured using a symptom diary, healthcare re-consultations, hospital admissions, and complications. Healthcare costs will be considered and expressed in 2021 euros (year foreseen to finalise the study) of the current year of the analysis. Univariate and multivariate sensitivity analyses will be carried out. Discussion The ISAAC-CAT project will contribute to evaluate the effectiveness and efficiency of different strategies for more appropriate antibiotic prescribing that are currently out of the scope of the actual clinical guidelines. Trial registration ClinicalTrials.gov, NCT03931577.

Background: How one responds to treatment of lupus nephritis (LN) is based on clinical features, but the activity in renal biopsy (RB) is uncertain. We have described the therapeutic decisions after performing a repeated RB on the assessment of response to intravenous cyclophosphamide (IC) and the possible prognostic role of this repeated RB. Methods: Clinical, laboratory and histological features at the initial RB and repeated RB were analyzed in 35 patients. Results: Data in the initial versus the repeated RB were serum creatinine 1.23 ± 1.08 and 0.96 ± 0.45 mg/dl (p < 0.05), glomerular filtration rate Conclusion: A repeated biopsy in LN distinguishes patients in true remission from those in apparent remission. By doing this, we can identify patients who could benefit from intensified treatment and for whom unnecessary treatment methods can be modified or eliminated.

We aimed to identify challenges and to propose solutions for the implementation of tuberculosis (TB) programmes in rural Sub-Saharan Africa (SSA) by evaluating the outcomes of the TB programme in the Ancuabe district in rural Northern Mozambique.Retrospective descriptive study of the patients included in the TB programme in 2012-2013. Follow-up was continued till June 2014.Three hundred nineteen patients were registered, 62.1% male, mean age 36.3 (SD 14.4), estimated case detection rate (eCDR) of 24.24%. Two hundred seventy-two were new cases, 21 transferred-in, 11 back after lost to follow-up (LTFU), 10 relapsing TB, 5 previous treatment failures. 94.4% were tested for Human immunodeficiency virus (HIV), 41.9% HIV-positive. 87.5% of the new cases were pulmonary TB (PTB), 43.4% were HIV co-infected. Initial sputum results were available in 207 cases, with 145 smear-positive (SP) cases. Outcomes of new cases: 122 (44.9%) LTFU, 55 (20.2%) cured, 43 (15.8%) treatment completed (98-36%-treatment success), 31 (11.4%) died, 19 (7%) transferred out and 2 (0.7%) failures.A low eCDR and high proportion of LTFU demonstrate that few patients were identified and had a low probability of complete treatment, suggesting a fragile health system. This raises the hypothesis that, probably, to improve TB health care in rural SSA, interventions should aim at improving health systems. Special attention should be given to social protection and compensation of the financial burden associated with TB.

BACKGROUND The impact of atrial fibrillation (AF) on mortality of patients with heart failure (HF) has been established. Nevertheless, the effect of some factors in mortality, such as digoxin or diuretic use, remains controversial. This study aims at assessing mortality in community-dwelling patients with stable HF related to AF and determines the relation of these drugs with prognosis. MATERIALS AND METHODS Community-based cohort study of HF patients diagnosed between January 2010 and December 2014 attended at any one of the 279 primary healthcare centres of the Catalan Institute of Health (Spain). Follow-up ended on December 31, 2015, and the main outcome was mortality for all causes. The effect of clinical and demographic characteristics on survival was assessed by Cox proportional hazards model. RESULTS A total of 13 334 HF patients were included. Mean age was 78.7 years (SD 10.1), and 36.8% had AF. Mean follow-up was 26.9 months (SD 14.0). At the end of the study, 25.8% patients had died, and mortality was higher when AF was present (28.8% vs 24.1%, P

The objective of the present study was to assess the diagnostic accuracy of the microscopic observation drug susceptibility (MODS) assay for tuberculosis (TB) diagnosis in HIV-infected patients.MEDLINE, EMBASE, LILACS, the Cochrane Central Register of Controlled Trials, African Index Medicus, ResearchGate, SciELO, and the abstracts of the main conferences on infectious diseases and tropical medicine were searched, and other sources investigated. Only studies including HIV-infected patients evaluating MODS for the diagnosis of TB and using culture-based diagnostic tests as a gold standard were analysed. Summary sensitivity and specificity were calculated with a bivariate model.3259 citations were found, 29 were selected for full-text review and 10 studies including 3075 samples were finally analysed. Overall diagnostic accuracy of MODS for the diagnosis of TB was a sensitivity of 88.3% (95% CI 86.18–90.2%) and specificity 98.2% (95% CI 97.75–98.55%). For multidrug-resistant (MDR)-TB, sensitivity was 89% (95% CI 66.07–97%) and specificity was 100% (95 CI 94.81–100%). For smear-negative pulmonary TB, a sensitivity of 88.2% (95% CI 86.1–89.9%) and specificity of 98.2% (95% CI 96.8–98.9%) were found. Costs varied between USD 0.72 and 7.31 per sample. Mean time to positivity was 8.24 days.MODS was found to have a good accuracy for the diagnosis of TB and MDR-TB in HIV-infected patients with low cost and fast results.

Resumen Fundamento y objetivo Estudios geneticos y farmacologicos sugieren que algunas vias de neurotransmisores influyen en la dependencia nicotinica. En esta linea se investigo el rol de 4 polimorfismos geneticos en genes relacionados con el control de impulsos: OPRM1, TPH1, ADRA2A y HTR1B. Se analizo el genotipo de una poblacion de 490 individuos no emparentados de Cataluna y se compararon las frecuencias genicas de fumadores, ex fumadores y no fumadores con el fin de descubrir correlaciones. Material y metodo Todos los polimorfismos se genotiparon en cada grupo de poblacion y se analizaron estadisticamente. Resultados Los datos obtenidos muestran que existe una relacion entre el sexo, la edad y el locus TPH1, que indica una tendencia hacia una menor frecuencia del genotipo AA en los ex fumadores. Conclusiones El polimorfismo del triptofano «TPH1» parece desempenar un papel como indicador de pronostico en la deshabituacion al tabaquismo.

Introduction For adequate disease control the World Health Organization has proposed the diagnosis and treatment of latent tuberculous infection (LTBI) in groups of risk of developing the disease such as children. There is no gold standard (GS) test for the diagnosis of LTBI. The objective of this study was to estimate the prevalence of LTBI in young children in contact with a household case of tuberculosis (TB-HCC) and determine the accuracy and precision of the Tuberculin Skin Test (TST) and QuantiFERON-TB Gold in-tube (QFT) used in the absence of a GS. Methods We conducted a cross-sectional study in children up to 6 years of age in Manaus/Brazil during the years 2009–2010. All the children had been vaccinated with the BCG and were classified into two groups according to the presence of a TB-HCC or no known contact with tuberculosis (TB). The variables studied were: the TST and QFT results and the intensity and length of exposure to the index tuberculosis case. We used the latent class model to determine the prevalence of LTBI and the accuracy of the tests. Results Fifty percent of the children with TB-HCC had LTBI, with the prevalence depending on the intensity and length of exposure to the index case. The sensitivity and specificity of TST were 73% [95% confidence interval (CI): 53–91] and 97% (95%CI: 89–100), respectively, versus 53% (95%CI: 41–66) and 81% (95%CI:71–90) for QFT. The positive predictive value of TST in children with TB-HCC was 91% (95%CI: 61–99), being 74% for QFT (95%CI: 47–95). Conclusions This is one of the first studies to estimate the prevalence of LTBI in children and the parameters of the main diagnostic tests using a latent class model. Our results suggest that children in contact with an index case have a high risk of infection. The accuracy and the predictive value of the two tests did not significantly differ. Combined use of the two tests showed scarce improvement in the diagnosis of LTBI.

Resumen En los ultimos anos, varios estudios han estimado la prevalencia de malnutricion en la poblacion anciana. El objetivo de esta revision sistematica es obtener una vision global sobre el estado nutricional de la poblacion anciana. Esta revision se ha basado en la recopilacion de estudios con informacion sobre la prevalencia de malnutricion publicados entre 1995-2011. Un total de 43.235 ancianos procedentes de 47 trabajos han sido seleccionados. Segun el Mini Nutritional Assessment, se observo un 16,6% (intervalo de confianza del 95% [IC 95%] 0-62) de malnutricion; con los parametros antropometricos o bioquimicos, se observo un 21,4% (IC 95% 2-77,3) de malnutricion; y con otros indices de evaluacion nutricional, se observo una malnutricion de 47,3% (IC 95% 10,6-94,7). Las tasas de prevalencia de desnutricion fueron mas altas en los estudios con gran proporcion de pacientes con discapacidad grave, fractura de cadera o problemas de deglucion. Se puede concluir que la malnutricion entre la poblacion anciana esta generalizada y es muy variable en funcion de los parametros utilizados, los problemas de salud asociados o el ambito de la poblacion. En los futuros estudios, el uso sistematico de cribados nutricionales en los hospitales, residencias o centros asistenciales mejoraria mucho el pronostico y la calidad de vida de las personas mayores, y facilitaria la comparacion entre los resultados de los estudios.

The slender-billed gull Chroicocephalus genei is a typical saltpan and brackishlagoon inshore forager. In 2005, there were two breeding colonies in the Ebro Delta (westernMediterranean): one south of the delta on a large saltpan, and the other one in the north, wheretypical foraging habitats are scarce. Aerial surveys showed that gulls foraged at sea throughoutthe study period, but were mainly restricted to the northern part of the delta from June to August.We compared 6 different approaches to model the gulls’ distribution at sea: Poisson generalizedlinear model (GLM), zero inflated Poisson GLM, spatial Poisson generalized linear mixed model(GLMM), non-spatial Poisson GLMM, negative binomial GLM and zero inflated negative bi -nomial GLM. The best approach, simple negative binomial GLM, suggested that the gulls’distribution was mainly influenced by the proximity to the colony, tern density and water temp -erature. The water temperature was indicative of river runoff, which resulted in an anchovypopulation explosion, explaining the gulls’ extensive foraging at sea in summer. Slender-billedgulls are capable of changing their foraging strategy to exploit resources at sea when occupyingan area with limited terrestrial but abundant marine resources. Population growth in the westernMediterranean may lead to the occupancy of non-typical habitats elsewhere. Because slender-billed gulls are rare and have an unfavorable conservation status, conservation policies affectingthis species should be extended to the sea.KEY WORDS

In areas with regular fishing coastal fleets seabirds may benefit from the predictability of discards from fishing vessels, but it is not clear to what extent birds rely on this predictable resource and whether foraging is synchronized with the diel availability of discards. In this paper we investigate if a typical scavenger species, the yellow-legged gull Larus michahellis, takes advantage of the temporal and spatial predictability of fish discards in the western Mediterranean Sea. The activity and distribution of the trawling fleet in this area is regulated and very predictable in time and space. We gathered aerial survey data across a relatively large area close to the coast to study the spatial distribution and density of L. michahellis, and modelled the density distribution of the species in relation to several oceanographic, ecological and temporal variables, using two different modelling approaches: MARS (multivariate adaptative regression splines) and GLM (generalized linear models). Our models suggest that the spatial density of trawlers at sea and the time of the day are the best explanatory variables of gull distribution, and that gulls concentrate in areas with vessels mainly during fish discarding time, supporting the hypothesis that gulls optimize time foraging to take advantage of fishery waste predictability. Additional surveys from the main gull roosting sites inshore support this hypothesis, as gulls start leaving to the sea just before fishing is completed and vessels begin discarding fish scraps when back to the harbour. This study represents one of the few examples of applying MARS to density distribution modelling, although its application to marine ecosystems should be conducted with caution because of large areas with real absence data. GLMs have shown to be more adaptable to such kind of data. Our data confirm the importance of fishery waste for L. michahellis, not only as a food resource but also as a major driver of their activity and distribution patterns. The ability of seabirds to predict accurately when a food resource will be available implies that modelling their distribution at sea needs to include such variables, both in spatial and temporal dimensions.

Resumen Antecedentes La desnutricion entre la poblacion anciana institucionalizada implica un aumento de la morbimortalidad. Uno de los posibles factores de riesgo podria ser la mala planificacion y adecuacion de los menus ofrecidos, que no llegan a cubrir las ingestas recomendadas en energia, macronutrientes y micronutrientes. Objetivo El objetivo de este estudio es analizar los menus planificados de cinco residencias geriatricas para valorar si se ajustaban a las ingestas recomendadas para este grupo de edad. Diseno El estudio se llevo a cabo en cinco residencias geriatricas, cuatro espanolas (Barcelona, Santa Coloma de Gramenet, Madrid y Bilbao) y una belga (Leuven). En cada una de las residencias se valoro un ciclo completo de menus (21 dias seguidos). El metodo de registro de alimentos fue de doble pesada, teniendo en cuenta la porcion no comestible de cada alimento ofrecido en el menu. Para la conversion de los menus a nutrientes, se utilizo la base de datos de composicion de los alimentos del Centro de Ensenanza Superior de Nutricion y Dietetica (CESNID) y la base de datos de composicion de alimentos de Belgica. Sujetos Se valoraron los menus de cinco residencias geriatricas durante un ciclo completo de 3 semanas (21 dias). De cada dia de menu, se valoraron los alimentos ofrecidos en las comidas principales: desayuno, comida, merienda y cena. No se tuvo en cuenta los alimentos ofrecidos fuera de los horarios establecidos por cada centro. Principales medidas de resultado Se analizo la cantidad total de energia, proteinas (%), hidratos de carbono disponibles (%), lipidos (%), acidos grasos saturados (%), acidos grasos monoinsaturados (%), acidos grasos poliinsaturados (%), calcio, hierro, fosforo, folatos, carotenos, vitamina C, vitamina D, vitamina E, retinol, tiamina, riboflavina vitamina B 6 y vitamina B 12 . Se compararon los valores obtenidos con los valores de referencia de las ingestas recomendadas (IR). Resultados Entre los menus estudiados, se detecto que no se cubrian la ingestas recomendadas para energia, hidratos de carbono, calcio, cinc, vitamina C, folatos y, sobre todo, vitamina D. Por el contrario, se detecto un exceso de lipidos, acidos grasos saturados y especialmente azucares de absorcion rapida. Conclusiones En funcion de los resultados obtenidos, seria recomendable que dietistas-nutricionistas llevaran a cabo una revision periodica de los menus ofrecidos en los centros geriatricos, para mejorar la planificacion y la calidad nutritiva, y programar politicas de enriquecimiento y/o suplementacion de menus cuando fuera necesario.

Anti-neutrophil cytoplasmic autoantibodies (ANCA)-associated disease among other manifestations can underlie rapidly progressive glomerulonephritis (RPGN), with crescentic and necrotizing GN. Differences in pathogenic immune mechanisms in RPGN may provide differences in the renal expression of adhesion molecules mediating these lesions. Renal intercellular adhesion molecule 1 (ICAM-1; CD54) and vascular cell adhesion molecule 1 (VCAM-1; CD106) were assessed in 40 patients with type I RPGN (anti-glomerular basement membrane antibodies, n = 4), type II (immune complexes, n = 17), and type III (ANCA, n = 19). Enzyme-linked immunosorbent assay (ELISA) for detection of immunoglobulin G antibodies against the Goodpasture’s antigen and indirect immunofluorescence and ELISA for myeloperoxidase (MPO) and proteinase 3 (PR3) were performed for ANCA testing. Ten normal renal tissues were used as controls. Relationships between ICAM-1 and VCAM-1, histopathologic features, and CD18, CD14, and CD3 cells were analyzed. Abnormal ICAM-1 and VCAM-1 in tubule was seen in >80% of biopsies with RPGN. Abnormal VCAM-1 in glomerular tuft was seen in >60% of biopsies with RPGN. Glomerular ICAM-1 was associated with less glomerulosclerosis (χ 2 = 6.719, p = 0.01), less interstitial fibrosis (χ 2 = 4.322, p

Radiotherapy for early vocal cord carcinoma affects quality of voice. Nevertheless, most patients refer to having a high satisfaction level with their voice. The few acoustic studies on quality of voice have been performed only in prolonged vowel production, which is not a usual speech situation. The present study has been done with the aim of establishing which phonetic situations reflect a greater alteration in voice production related to irradiation.Eighteen male patients irradiated for Tis-T1 vocal cord carcinoma and a control group of 31 non-irradiated subjects were included in a study of acoustic voice analysis. This analysis was performed one year after radiotherapy. Patients and control group voices were tape recorded in extended vowel production, oral reading of a standard paragraph, spontaneous speech and in a song. Acoustic analysis was performed by a Kay Elemetric's Computerized Speech Lab (model CSL #4300). Fundamental frequency, jitter, shimmer and harmonics-to-noise ratio were obtained in both groups. Statistical test: Lin concordance coefficient and Pearson's correlation coefficient, Student's t-test and ROC curves.Concordance and correlation studies did not allow selection of any subgroup in acoustic parameters and different acoustic situations. Acoustic parameters had higher median values in irradiated patients. Student's t-test showed significant differences for fundamental frequency in sustained vowel production and spontaneous speech; for jitter there was statistical significance in all the acoustic situations and for shimmer in oral reading and song. Jitter showed a cut-off of 2.02% with a sensitivity of 89% and specificity of 97% in classifying irradiated and non-irradiated groups. The ROC curve for jitter correctly classified 94% of subjects into irradiated or non-irradiated groups.The present study showed that jitter obtained from spontaneous speech was the most relevant parameter in discriminating voice in irradiated patients by acoustic analysis. Jitter in spontaneous speech is in need of more analysis in bigger series and in more advanced stages of larynx cancer as its relevance has been demonstrated.

INTRODUCTION: Few studies have described the risk factors of intestinal parasitic infections in the Amazon. METHODS: A cross-sectional survey was performed in a City of the State of Amazonas (Brazil) to estimate the prevalence of intestinal parasites and determine the risk factors for helminth infections. RESULTS: Ascaris lumbricoides was the most prevalent parasite. The main risk factors determined were: not having a latrine for A. lumbricoides infection; being male and having earth or wood floors for hookworm infection; and being male for multiple helminth infections. CONCLUSIONS: We reported a high prevalence of intestinal parasites and determined some poverty-related risk factors.

The improvement of the convergence rate of the parameter estimation process is dealt with in the context of disease mapping when generalized linear mixed models are used. Two transformations of the random effects covariance matrix parameters are proposed with the aim of forcing the resulting estimates into their domain. The increased convergence rate using these transformations is shown through a simulation study. The approach is illustrated with reference to Scottish lip cancer data and insulin-dependent diabetes mellitus data from Catalonia. Both datasets suffer problems of convergence which are solved using the transformed parameters.

The development of the geographic information systems has improved the interest in analyzing the characteristics of the population, taking into account the place where they live. The health of the population, measured as the risk of morbidity or mortality, is conditioned by the variety of risk factors characteristic of the region which cannot be measured. Analysis of spatial models considers the dependence of the health indicators between close regions. This dependence is due to the existence of the risk factors that are not measured but are shared by the region. Thus, the spatial distribution of these indicators depends on the geographic pattern of these risk factors. In this study, some limitations of the standardized methods and the Poisson regression used to model the spatiality are discussed and the advantages of the spatial models are shown. The methodology is illustrated by the insulin-dependent diabetes type 1 data from Catalonia during 1989 and 1998.

When performing nutritional epidemiology studies, missing values and outliers inevitably appear. Missing values appear, for example, because of the difficulty in collecting data in dietary surveys, leading to a lack of data on the amounts of foods consumed or a poor description of these foods. Inadequate treatment during the data processing stage can create biases and loss of accuracy and, consequently, misinterpretation of the results. The objective of this article is to provide some recommendations about the treatment of missing and outlier data, and orientation regarding existing software for the determination of sample sizes and for performing statistical analysis. Some recommendations about data collection are provided as an important previous step in any nutritional research. We discuss methods used for dealing with missing values, especially the case deletion method, simple imputation and multiple imputation, with indications and examples. Identification, impact on statistical analysis and options available for adequate treatment of outlier values are explained, including some illustrative examples. Finally, the current software that totally or partially addresses the questions treated is mentioned, especially the free software available.Cuando se realiza un estudio epidemiológico nutricional, es inevitable que aparezcan valores ausentes y atípicos. Los datos ausentes aparecen, por ejemplo, por la dificultad de recoger los datos en las encuestas dietéticas que conducen a una falta de información sobre la cantidad de alimentos consumidos y una pobre descripción de ellos. Un inadecuado tratamiento durante el proceso de recolección nos conduce a sesgos y pérdida de precisión y consecuentemente una incorrecta interpretación de los resultados. El objetivo de este artículo es proporcionar recomendaciones sobre el tratamiento de datos ausentes y atípicos, y algunas orientaciones sobre el software existente para calcular el tamaño de muestra y realizar el análisis estadístico. También se realizan recomendaciones sobre la recolección de datos que es un paso importante en la investigación nutricional. Se comentan los métodos que se usan para hacer frente a los datos ausentes, específicamente, el método eliminación de casos, imputación simple o múltiple con indicaciones y ejemplos. También se relata cómo se identifican datos atípicos, el impacto que tienen en el análisis estadístico, las opciones para un adecuado tratamiento y se ilustra mediante un ejemplo. Finalmente, se menciona el software existente que aborda total o parcialmente las cuestiones tratadas, específicamente el software de libre distribución.

In nutritional epidemiology, it is essential to use Food Consumption Assessment Methods that have been validated and accepted by the international community for estimating food consumption of individuals and populations. This assessment must be made with the highest quality possible so as to avoid, as far as possible, sources of error and confusion in the processes. The qualities that are required in a measurement method are validity and accuracy; validity being the main factor. Lack of validity produces biases, or systematic errors. These can reside in the process of subject selection, or processes of information gathering where the lack of accuracy produces random errors. For many nutrients, the intra-individual variances are due to many factors such as day-of-the-week or season, and could create problems in the data analyses. Adjustments are needed to minimize these effects. Confounding factors may over- or under-state the real magnitude of the observed association, or even alter the direction of the real association. Total energy intake can be a confounding variable when studying a relationship between nutrient intake and disease risk. To control for this effect several approximations are proposed such as nutrient densities, standard multivariate models and the nutrient residual model.En la epidemiología nutricional es esencial la utilización de los Métodos Valoración del Consumo Alimentario validados y aceptados por la comunidad internacional para estimar el consumo alimentario de los individuos y grupos de población. Esta estimación debe hacerse con la mayor calidad posible, evitando, en la medida de lo posible, las fuentes de error y confusión en la medida del consumo alimentario. Las cualidades que otorgan calidad a un método de medida son la validez y la precisión, siendo la validez la principal característica. La falta de validez produce sesgos o errores sistemáticos, los cuales pueden ser en el proceso de selección de los sujetos o en el proceso de obtención de la información; y la falta de precisión produce errores aleatorios. Para muchos nutrientes, las variaciones intra-individuales debidas a muchos factores como el día de la semana o la estación del año, podrían crear problemas en los análisis de datos. Para minimizar este efecto se deben realizarse algunos ajustes en los análisis. Los factores de confusión pueden exagerar o subestimar la verdadera magnitud de la asociación o incluso alterar la dirección de la asociación. El consumo total de energía puede ser una variable de confusión en el estudio de la relación entre la ingesta de nutrientes y el riesgo de enfermedad. Para controlar este efecto se proponen varias aproximaciones: la densidad de nutrientes, modelo multivariado estándar y el modelo residual de nutrientes.

Background: Sarcomatous neoplasms of the uterine corpus are still a challenge in terms of obtaining prognostic factors and the most optimum complementary treatment to surgery. The most important prognostic factor is stage; relapses usually appear during the first 2 years, and most patients die within the first 3 years. We have performed a multivariate study of prognostic factors, stratifying patients by stage, to determine their impact on overall survival, disease-free survival, local relapse-free survival, and distant metastasis-free survival. Special emphasis has been given to vascular and lymphatic space invasion (VLSI). Methods: Sixty patients diagnosed with uterine neoplasms with a main sarcomatous component were treated at Hospital Clinic i Universitari of Barcelona between January 1975 and June 1999. Pathologic type : 32 carcinosarcomas, 14 leiomyosarcomas, 9 adenosarcomas, and 5 endometrial stromal sarcomas. Treatment : 58/60 surgery, 35/60 postoperative radiotherapy, 2/60 exclusive chemotherapy, and 3/60 complementary chemotherapy. FIGO stages : 43 Stage I, 4 Stage II, 11 Stage III, and 2 Stage IV. Variables analyzed : age, stage, vascular and lymphatic space invasion, myometrial invasion, mitotic index, tumor size, unicentricity/multicentricity, necrosis, and radiotherapy. Statistics : the S and Cox proportional risk models. The partial effect of each risk factor was calculated by hazard ratio (HR) with a confidence interval of 95%. Results: Early stages : Multivariate analysis showed that tumor size larger than 8 cm and VLSI had an impact on overall survival (HR = 4.01 and HR=24.45, respectively). VLSI was present in 23% of the cases. Myometrial invasion greater than 50% had an impact on disease-free survival and local relapse-free survival (HR was 9.75 and 3.20, respectively). VLSI had an impact on distant metastasis-free survival (HR = 2.92). Advanced stages : VLSI was present in 89% of the cases. Only leiomyosarcoma type made the overall survival worse (HR = 10.54). Conclusions: Vascular and lymphatic space invasion was a relevant prognostic factor in our series, with an impact on overall survival and distant metastasis-free survival in early stages. In advanced stages, VLSI had no impact on survival, but was present in 89% of cases. Myometrial invasion >50% had an impact on local relapse. Advanced stages had a more aggressive behavior, and there was a higher incidence of poor prognostic factors in these stages. Nevertheless, prospective studies are still needed on prognostic factors and on the best treatment option.

Two key aims of diagnostic research are to accurately and precisely estimate disease prevalence and test sensitivity and specificity. Latent class models have been proposed that consider the correlation between subject measures determined by different tests in order to diagnose diseases for which gold standard tests are not available. In some clinical studies, several measures of the same subject are made with the same test under the same conditions (replicated measurements), and thus, replicated measurements for each subject are not independent. In the present study, we propose an extension of the Bayesian latent class Gaussian random effects model to fit the data with binary outcomes for tests with replicated subject measures. We describe an application using data collected on hookworm infection carried out in the municipality of Presidente Figueiredo, Amazonas State, Brazil. In addition, the performance of the proposed model was compared with that of current models (the subject random effects model and the conditional (in)dependent model) through a simulation study. As expected, the proposed model presented better accuracy and precision in the estimations of prevalence, sensitivity and specificity. Copyright © 2017 John WileySons, Ltd.

Background The feminization of medicine has risen dramatically over the past decades. The aim of this article was to compare the advance of women with that of men and determine the differences between hierarchical status and professional recognition achieved by women in medicine. Methods A retrospective study was carried out in the Hospital Clinic Barcelona, Spain, of the period from 1996 to 2008. Data relating to temporary and permanent positions, hierarchy and career promotion achieved, specialty, age and the sex of the participants were analysed with the ANOVA test and logistic regression using the generalized estimated equation. Results After completion of specialist training, fewer women than men doctors obtained permanent positions. The ratios between the proportions of women and men remained 1.2 for permanent non-hierarchal medical positions and below 0.2 for higher hierarchal levels. Fewer women than men with hierarchy and fewer women than men achieved the rank of consultant. Promotion to consultant and senior consultant was lower than that to senior specialist, being higher in specialties with gender parity and in masculinised specialties. On comparing the two genders using a statistical model, the probability of continuous promotion decreased with the year of the application and the age of the applicant, except in women. Conclusions Despite the number of women training as specialists having increased to 50%, women remained in temporary positions twofold longer than men. Compared to women, men showed significant representation in hierarchal medical positions, and women showed a lower adjusted probability of internal professional promotion throughout the study period.

Fundamento Conocer el significado clinicopatologico de la expresion renal de ICAM-1 en la nefropatia mesangial por IgA (NIgA). Pacientes y metodo Se identifico la expresion tubular e intersticial ICAM-1 (CD54) en 45 pacientes con NIgA y 29 pacientes con nefropatia no glomerulonefritis (NnoGN), analizandose su relacion con la histologia y la clinica en el momento de la biopsia renal y al cabo de 2,4 (2) (media [DE]) anos en la NIgA y de 1,8 (1,5) anos en la NnoGN. Resultados En 25 biopsias de NIgA (55%) se aprecio expresion de ICAM-1 en el tubulo asociada a proliferacion extracapilar (p 2 , y se correlaciono con la esclerosis glomerular en menos (r = 0,386; p 2 leucocitos intersticiales ICAM-1 positivos, frente a 66 (87,8)/mm 2 p 2 . Hubo correlacion (r = 0,4356; p Conclusiones La expresion tubular e intersticial de ICAM-1 podria ser un marcador de lesion tubulointersticial en la NIgA. La presencia de ICAM-1 intersticial mas que ICAM-1 tubular indicaria la progresion de la enfermedad en la NIgA.